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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700854
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:21:35 PM

Document Has Been Signed on 08/20/2024 03:21 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:ALEXA'S ELDERLY CARE #2FACILITY NUMBER:
342700854
ADMINISTRATOR/
DIRECTOR:
ROZOLEANU, ALEXANDRAFACILITY TYPE:
740
ADDRESS:6905 LE HAVRE WAYTELEPHONE:
(916) 634-6304
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Administrator: Carmen IonTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On 08/20/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the care tool. LPA met with Administrator Carmen Ion and explained the purpose of the visit. Facility currently has six (6) resident and a has a hospice waiver for three (3) residents. There is currently no residents receiving hospice services.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but are not limited to: resident bedrooms, bathrooms, common areas, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies locked are inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 109 degrees Fahrenheit, which is within the required range of 105 to 120 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher, which is located in the kitchen, was last serviced on 03/29/2024. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed four (4) resident files, which contains signed admission agreements, physician's reports, identification sheets, consent forms, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for three (3) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in medications, first aid/CPR, and other various areas.

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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