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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700957
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:55:41 PM

Document Has Been Signed on 04/26/2023 03:55 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:SENIOR CARE @ DIAMOND OAKSFACILITY NUMBER:
342700957
ADMINISTRATOR:MACIUCA, ESTERAFACILITY TYPE:
740
ADDRESS:219 DIAMOND OAKS RD.TELEPHONE:
(916) 470-1416
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 5DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Estera MaciucaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/26/232 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home was found to be clear, safe and sanitary.

LPA reviewed 5 resident files and 2 staff files. LPA advised by LPA to maintain more complete documentation of training and first aid certificates in staff files. LPA and licensee discusses updating 2 resident LIC 602s (physician report) and they are in process with family and providers.

LPA requested licensee submit a copy of liability insurance.

A designee / backup Administrator has been dropped in Guardian. Licensee will submit a transfer request.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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