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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005010
Report Date: 04/17/2024
Date Signed: 04/17/2024 02:37:42 PM

Document Has Been Signed on 04/17/2024 02:37 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:ALL SEASONS, LLCFACILITY NUMBER:
347005010
ADMINISTRATOR/
DIRECTOR:		ANATOLIY MOLITVENIKFACILITY TYPE:
740
ADDRESS:8731 CENTRAL AVENUETELEPHONE:
(916) 776-6665
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Operations Director, Galina Chikivchuk TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 04/17/24, Licensing Program Manager (LPM), Laura Munoz and Licensing Program Analysts (LPAs) Talwinder Bains and Cheyenne Ratajczak arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 04/05/24. LPAs and LPM met with Operations Director, Galina Chikivchuk and explained reason for visit.

The facility submitted an incident report (LIC624) and SOC341 to the Department on 04/08/24. Incident report indicated a staff at the facility slapped a resident while in care on 04/05/24. Department conducted record review , interviewed staff and residents regarding this incident. Based on this information,Department has concluded that facility was failed to provide safe environment to resident , R1 and violated R1s personal rights.

Citation has been issued per CCR, Title 22 Regulations, Appeal Rights and copy of the report has been provided after exit meeting.









SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 04/17/2024 02:37 PM - It Cannot Be Edited


Created By: Talwinder Bains On 04/17/2024 at 01:31 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: ALL SEASONS, LLC
FACILITY NUMBER: 347005010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1- Personal Rights of Residents in All Facilities ..(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons....this requirement is not met as evidence by;
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Administrator will send letter of statement for understanding of this regulation and will conduct staff training .All POC documents are due by POC date-04/18/24.
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Record review and interviews indicated that Facility staff ,S1 slapped resident, R1 while in care on 04/05/24 which is violation of this regulation and poses immediate health and safety risks for 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: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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