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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700767
Report Date: 01/26/2022
Date Signed: 01/27/2022 07:07:32 AM

Document Has Been Signed on 01/27/2022 07:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ALLTRUE CARE LLCFACILITY NUMBER:
342700767
ADMINISTRATOR:KACHAN, VICTORIAFACILITY TYPE:
740
ADDRESS:9977 WYLAND DRIVETELEPHONE:
(530) 215-8388
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
01/26/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Victoria KachanTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the care home to conduct an unannounced Annual Inspection. Facility Administrator Victoria Kachan was informed of the purpose of the visit and was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility has submitted a written mitigation plan (LIC 808) and LPA reviewed and discussed the plan and current Licensing guidance.. Administrator's Certification for Victoria Kachan is 6048846740 expires 8/5/22.

LPA toured the facility and reviewed the Mitigation Plan as well as discussing COVID Training Procedures during the Inspection. Smoke alarms and smoke detectors are hard wired to the facility, were tested are operational. Fire extinguishers were serviced in April 2021 and are in compliance. Facility has carbon monoxide detectors that are operational. Medication were locked and facility was determined to have an adequate food supply. Facility's PPE supplies were observed and determined to be adequate for a 30 supply.

The interior and outdoor area of the home was inspected including bedrooms, kitchen, bathrooms, and common areas for this home. There are five clients in the home and 5 client bedrooms, There are two client bathrooms that were viewed and are in compliance with grab bars and non-skid mats. One resident is on hospice and several with dementia.

Continued
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ALLTRUE CARE LLC
FACILITY NUMBER: 342700767
VISIT DATE: 01/26/2022
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All staff on site have the required criminal record clearance. LPA observed the following posted in the facility: Hand washing and visitation policies, Visitation signs. Resident Personal Rights, Evacuation Routes and facility license were all posted as required. Current LIC 500, LIC 308, and LIC 309 to be updated and submitted to Licensing as needed

Exit interview conducted with Victoria Kachan, no deficiencies were identified and a copy of report given at the conclusion of the visit
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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