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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002823
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:38:39 PM

Document Has Been Signed on 03/06/2025 04:38 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:WHOLESOME ELDERLY ON KIFISIAFACILITY NUMBER:
345002823
ADMINISTRATOR/
DIRECTOR:		FAAMAUSILI,CHRISFACILITY TYPE:
740
ADDRESS:6024 KIFISIA WAYTELEPHONE:
(916) 678-0268
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 5DATE:
03/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Juan Ramirez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Juan Ramirez, to conduct a case management visit in relation to a separate inspection conducted on today's date, 3/06/2025.

LPA observed medications to be accessible to the residents in care with medication cabinet remaining unlocked upon entry of the care home. LPA also observed kitchen sink to be leaking, with water underneath the sink and a towel on the floor to soak up water coming from the kitchen sink.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Civil penalties were assessed as a result of today's visit. Deficiencies are listed on 809-D pages.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/06/2025 04:38 PM - It Cannot Be Edited


Created By: Michael Hood On 03/06/2025 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2025
Section Cited
CCR
87465(h)(2)

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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:
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Facility locked unlocked medication storage during visit. Facility will complete a statement of understanding and submit statement to LPA by POC due date of 3/07/2025. A civil penalty in the amount of $250 was issued for a repeat violation.
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Based on LPA's observations, facility did not ensure that centrally stored medication was locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
03/21/2025
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Facility will hire services to fix kitchen sink. Facility will submit proof of services to LPA by POC due date. A civil penalty in the amount of $250 was issued for a repeat violation.
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Based on LPA's observations, staff did not ensure facility was in good repair when kitchen sink was leaking, which poses a potential health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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