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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920183
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:56:05 PM

Document Has Been Signed on 10/02/2024 02:56 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:RC PREMIER VILLA 1FACILITY NUMBER:
345920183
ADMINISTRATOR/
DIRECTOR:
CABRERA, ZADELFACILITY TYPE:
740
ADDRESS:8134 ROBERT CREEK COURTTELEPHONE:
(925) 567-8181
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Zadel Cabrera, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada conducted a scheduled Pre-Licensing Inspection on 10/2/24 (10:00 am). LPA met with Zadel Cabrera, Administrator. Also present was caregiver, Karmen Szilvassy. LPA observed (2) residents sitting in the common area and (2) residents resting in their rooms. Administrator for the current license, Marikar King, was also present. Later during the inspection, members for the pending license, Juvy Bartolome and Angeline Lardizabal, arrived and participated in the inspection. The reason for the pre-licensing is due to a change in ownership. The facility is currently licensed for (6) non-ambulatory residents, (2) of whom are approved for hospice. Currently there are no hospice residents.

LPA and others toured the interior and exterior of the facility, including the common areas, resident bedrooms, staff rooms, bathrooms, kitchen, laundry and patio. The facility was observed to be clean, in good repair and have sufficient furniture and lighting throughout. Resident bathrooms have grab bars and non-skid flooring, and there are (20) second hand-washing posters by each sink. There is sufficient 2+day perishable and 7+day non-perishable supply of food. The hot water measured 116*F in the kitchen and the inside temperature measured 77*F. There is an additional refrigerator with a locked box for medications. Sharps are locked in the kitchen and toxins are locked in a separate cabinet in the common area. All doors have working alarms, and the fire extinguisher was last serviced 7/25/24. The smoke/monoxide alarms are working, and the fire door automatically closed when the alarms were tested. There are blankets/linens/PPE supplies on hand. Residents use a necklace pendant to call for assistance. There is one unlocked exit.

All required postings are posted in the common area. Inside temperature measured 77*F. Resident and staff binders are organized and complete.

Comp III was conducted during today's inspection. Pre-licensing is complete and this facility has no deficiencies. LPA to notify analyst in application unit.

Exit interview. Copy of report provided to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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