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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700416
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:51:34 PM

Document Has Been Signed on 12/21/2023 02:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ELDERLY INN IV, THEFACILITY NUMBER:
342700416
ADMINISTRATOR:TOPLEAN, SAMFACILITY TYPE:
740
ADDRESS:4908 ILLINOIS AVETELEPHONE:
(916) 844-7025
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 6DATE:
12/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Sam Toplean, AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Sam Toplean, to follow-up on a plan of correction made to the facility on 11/30/2023 to be completed on 12/31/2023.

During today's visit, LPA took the temperature of the water and found temperature to be 113.3 degrees F.

LPA cleared deficiency during visit.

Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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