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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002929
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:25:15 PM

Document Has Been Signed on 03/14/2023 03:25 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:DEAN ESTATEFACILITY NUMBER:
345002929
ADMINISTRATOR:RAMOS, KARLFACILITY TYPE:
740
ADDRESS:5214 NORTH AVETELEPHONE:
(916) 934-4234
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
03/14/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Noel EstilloreTIME COMPLETED:
02:40 PM
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On 3/14/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post-licensing inspection utilizing the post-licensing inspection tool. LPA met with Assistant Administrator (Asst Admin), Noel Estillore, and explained the purpose of the inspection. Today's census is 6 with (1) resident on hospice services. Facility is licensed for capacity of 6 and hospice waiver of 6.

At entrance, LPA observed S1 to not have a mask on. LPA informed S1 of PIN 23-02 ASC, licensee is to follow strictest guideline as CCLD is requiring all staff and visitors to wear mask indoor. LPA observed S1 to put on mask immediately. LPA additionally informed Asst Admin of the recent PIN 23-05 ASC of the informational call discussing anticipated new guidelines.

LPA and Asst Admin conducted a tour together to ensure the health and safety of residents in care. In areas toured included but not limited to the common areas, kitchen, dining room. laundry room, staff restroom, resident private bedrooms and bathrooms. LPA observed the Administrator Certificate to be updated. LPA and Asst Admin discussed the required documents to be submitted to LPA to change Administrator of the facility. LPA observed the require postage posted on the wall. LPA observed the kitchen to have sharps and medication to be locked and secured.

LPA conducted a file review of resident records (2) of (6). LPA was unable to conduct personnel file review as the files were stored next door at a sister facility.

LPA and Asst Admin completed the post-licensing inspection tool. As a result of today's inspection, no deficiencies cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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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