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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004228
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:14:08 PM

Document Has Been Signed on 10/01/2024 12:14 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:FOUR SEASONS CARE HOMEFACILITY NUMBER:
347004228
ADMINISTRATOR/
DIRECTOR:		IOAN NAGYFACILITY TYPE:
740
ADDRESS:8322 CENTRAL AVENUETELEPHONE:
(916) 910-9419
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 4DATE:
10/01/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Ioan Nagy TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On 10/01/2024 at 10:30AM, an informal conference was conducted with Sacramento Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to discuss the deficiencies observed within last 3 years and to address current issues at facility. Present in the meeting were, Licensing Program Manager (LPM) Lauren Crocker, Licensing Program Analyst (LPA) Talwinder Bains, and licensee/administrator, Ioan Nagy. The Administrator was told that this Informal conference is a part of the Administrative Action process, and that further noncompliance may result in an elevation to a formal noncompliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. The informal conference process was explained during this meeting.

Issues discussed during the meeting were:
- Expired Administrator’s Certificate
- Staff’s training records and other required documents in staff’s files
- Expired Food Items
- Facility’s Operation and Maintenance
- Expired fire extinguisher and non-compliant with required fire and disaster quarterly drills
- Missing required documents in resident’s files
- Issues with medications management
The facility has stated they will do the following to achieve continued and substantial compliance:
• Submit a letter of understanding of Title 22 by 10/15/24
• Reach out to Community Care Licensing Division (CCLD) as a resource.
Technical Support Program (TSP) was offered and accepted.

Deficiencies were cited per Title 22 Regulations as listed on LIC809-D. Exit interview conducted. Informal meeting concluded, Appeal Rights and a copy of report was provided to the facility via email. Civil penalties may be assessed if facility does not comply with POC requirements which were issued today.

A copy must be signed and returned to the Department by 10/01/24 by 5PM.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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 10/01/2024 12:14 PM - It Cannot Be Edited


Created By: Talwinder Bains On 10/01/2024 at 11:56 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: FOUR SEASONS CARE HOME
FACILITY NUMBER: 347004228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87405

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87405-Administrator - Qualifications and Duties- (d) The administrator shall have the qualifications .......If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements ......(2)Knowledge of and ability to conform to the applicable laws, rules and regulations……this requirement is not met as evidence by;
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Licensee shall hire a qualified administrator and shall notify Department by POC date-10/31/24 . Furthermore, if Licensee wishes to work as administrator, Licensee shall fulfill all required compents and shall renew thier administrator's certificate per Department guidelines.
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Based on record review and staff's interviews, facility does not have a qualified Administrator which poses a potential health and safety risks to residents 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:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
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