Community Care Licensing

Document Has Been Signed on 01/07/2025 03:21 PM - It Cannot Be Edited

FACILITY NAME:	WHOLESOME ELDERLY ON KIFISIA		FACILITY NUMBER:	345002823
ADMINISTRATOR/ DIRECTOR:	FAAMAUSILI,CHRIS		FACILITY TYPE:	740
ADDRESS:	6024 KIFISIA WAY		TELEPHONE:	(916) 678-0268
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY: 6		CENSUS: 5	DATE:	01/07/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Juan Ramirez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

SUPERVISORS NAME: Anthony Perez LICENSING EVALUATOR NAME: Michael Hood LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025

Link to Parent Document Below:

FACILITY NAME: WHOLESOME ELDERLY ON KIFISIA	FACILITY NUMBER: 345002823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/08/2025 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care Services (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility locked unlocked medication storage during visit. Facility will complete an in-service training for staff regarding medications. Facility will submit date of training and training materials to LPA by POC due date of 1/08/2025.
	8 9 10 11 12 13 14	Based on LPA's observations, facility did not ensure that centrally stored medication was locked and inaccessible to the residents in care when key to medications was left in medication cabinet, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	A civil penalty in the amount of $250 was issued for a repeat violation.
Type B 01/22/2025 Section Cited CCR87307(a)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will remove bedroom set up in garage by POC due date of 1/22/2025.
	8 9 10 11 12 13 14	Based on LPA's observations, facility did not ensure that staff were not sleeping in an area designated for sleep when establishing a staff bedroom in a space designated as the garage, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Michael Hood LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025