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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700877
Report Date: 10/09/2024
Date Signed: 10/09/2024 01:19:45 PM

Document Has Been Signed on 10/09/2024 01:19 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:ROBERT CREEK VILLA IFACILITY NUMBER:
342700877
ADMINISTRATOR/
DIRECTOR:		SBINGU, ADINAFACILITY TYPE:
740
ADDRESS:8135 ROBERT CREEK VILLA COURTTELEPHONE:
(916) 745-4230
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Adina Sbingu, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Mariana "Mimi" Musca, caregiver, and stated reason for the inspection. Mariana contacted the Administrator, Adina, by phone, who arrived at approximately 10:30 am. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). LPA was advised (2) residents are currently under hospice care. LPA observed all (6) residents to be present the facility.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms with private bath, (2) full bathrooms, kitchen, (3) staff rooms and garage/locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. The bathrooms have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+day perishable and 7+day non-perishable supply of food. Sharps and toxins are locked. Hot water temperature measured 113*F in a resident bathroom. Fire extinguisher was last serviced 8/2/24, and the smoke/monoxide alarms are working. Fire doors are kept open with approved device and close automatically when the alarms are activated. Fireplace is used as storage only. There is a locked medication box in the refrigerator, and medications are locked in a separate cabinet. LPA observed the inside temperature to be 79*F. There is a First Aid kit on site as well as sufficient paper/incontinent products, including PPE. All required postings are posted.There is a covered patio table outside and (1) unlocked exit. There are no pools or bodies of water.

(2) resident files were reviewed and were found to contain current/complete documentation. Meds were reviewed for (1) resident and orders matched meds being administered. LPA reviewed all staff files and observed current First Aid/CPR certification and documentation of completed annual training. LPA requested an updated copy of LIC500, LIC308 and current liability insurance today by 10/16/24.

There are no deficiencies issued during today's inspection. Exit interview with Administrator. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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