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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920099
Report Date: 05/16/2024
Date Signed: 05/16/2024 11:42:45 AM

Document Has Been Signed on 05/16/2024 11:42 AM - 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:SPRING AZURE SENIOR CAREFACILITY NUMBER:
345920099
ADMINISTRATOR/
DIRECTOR:		CHUA-HARRIS, CHRISTINE DYAFACILITY TYPE:
740
ADDRESS:6924 OAK SPRING WAYTELEPHONE:
(916) 579-9222
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator- Christine Chua- HarrisTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 05/16/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a post- licensing visit utilizing the care tool. LPA met with Administrator, Christine Chua- Harris and explained the purpose of the visit. The facility was licensed on/around 02/13/24 for six (6) non-ambulatory residents and has an approved hospice waiver for four (4). Currently, there are six (6) residents and no one receiving hospice services.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: resident bedrooms, bathrooms, kitchen, garage, and backyard. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, knives and medications are locked and inaccessible to residents in care. Hot water temperature was measured at 117.2 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 74 degrees. Fire extinguisher was last inspected on 11/06/23. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed required Licensing posters posted throughout the facility.

LPA conducted a file review of two (2) resident files and one (1) staff file. LPA observed one (1) staff working at the facility who is not fingerprint cleared. Administrator stated they will send staff today to get fingerprinted. LPA additionally provided facility with LIC311f which states required documents for personnel and resident files.

LPA completed the full care tool, deficiencies was observed and civil penalties was assessed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 05/16/2024 11:42 AM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 05/16/2024 at 11:26 AM
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: SPRING AZURE SENIOR CARE
FACILITY NUMBER: 345920099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above due to caregiver not being fingerprint cleared which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Licensee removed caregiver from the facility immediatly. Caregiver cannot come back to facility until fingerprint cleared. Licensee will submit a statement of understanding to LPA Ratajczak that all staff must be fingerprint cleared prior to wokring in the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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