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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920073
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:40:50 PM

Document Has Been Signed on 11/20/2024 02:40 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 MAR VISTAFACILITY NUMBER:
345920073
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, JUANFACILITY TYPE:
740
ADDRESS:7401 MAR VISTA WAYTELEPHONE:
(916) 678-0268
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 5DATE:
11/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Administrator- Juan RamirezTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 11/20/24, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a case management visit. LPAs met with Administrator, Juan Ramirez and explained the purpose of the visit.

During LPAs visit on 11/07/24 it was observed that in the backyard there is a piece of sidewalk that has lifted a couple inches due to a tree root growing underneath. This pathway is part of the facilities emergency exit. Facility does have non-ambulatory residents in care that are not able to use that pathway due to the lifting of the sidewalk.

As a result of the inspection, deficiencies were observed and cited.

Exit interview conducted and a copy of report and appeal rights provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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Document Has Been Signed on 11/20/2024 02:40 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 11/20/2024 at 02:31 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 MAR VISTA
FACILITY NUMBER: 345920073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2024
Section Cited
CCR
87307(d)(6)

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87307Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
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Licensee is to fix passageway to ensure it is not obstructed. Licensee will send LPA a picture of passageway once fixed by POC due date.
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Based on observation, the licensee did not comply with the section cited above due to passageway not being free of obstruction which poses a potential health and safety risk to persons 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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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