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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002864
Report Date: 02/11/2025
Date Signed: 02/11/2025 05:16:41 PM

Document Has Been Signed on 02/11/2025 05:16 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:OLD RANCH VILLAFACILITY NUMBER:
345002864
ADMINISTRATOR/
DIRECTOR:
RONSTADT, STEVENFACILITY TYPE:
740
ADDRESS:8312 BLAYDAN CTTELEPHONE:
(844) 759-6387
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 6DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Kelly Conley, House ManageTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Aneitta Simpson, caregiver, who contacted Kelly Conley, House Manager, who arrived at 3:15 pm.
Also present was care staff, Mischka Smith. LPA observed (1) resident to be resting in the common area watching television and (5) residents to be in their resident rooms. The facility is licensed for (6) non-ambulatory residents. There is a hospice waiver approved for (3) residents. Currently there is (1) resident on hospice.

LPA and House Manager toured the interior/exterior of the facility including the common areas, (6) resident bedrooms, (4) resident full bathrooms and (1) resident/staff bathroom, kitchen, laundry area and garage. All but (1) resident room has an exit door to the outside. LPA observed the facility to be clean, in good repair and odor-free and the bathrooms to 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, and locked sharps in the kitchen. Locked medications are in a separate closet nearby. LPA observed locked toxins in the garage and laundry area. Inside temperature measured 76*F, and hot water measured 120*F in the kitchen. The fire extinguisher was last serviced 6/18/24 and facility conducts quarterly emergency drills. There is sufficient incontinent/linens/towels/blankets and PPE products. RCFE Administrator Certificate #6051256740- exp 2/26/2025- all required have been completed- renewal paperwork to be submitted this week. There is (1) unlocked gate f and no bodies of water/pool.

LPA reviewed (2) resident files and medications for (1) resident. Files are organized and contain the required documents. Medications are being administered per orders. (3) staff files were reviewed- all staff have completed the initial/ongoing required training and have current First Aid/CPR certifications. All staff is fingerprint cleared/associated. There is (1) awake staff during the night.
Administrator to email a copy of an updated copy of LIC500, LIC308 and current liability insurance.
There are no deficiencies issued in this report. Exit interview. Copy of report
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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