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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005577
Report Date: 08/10/2023
Date Signed: 08/12/2023 03:27:18 PM

Document Has Been Signed on 08/12/2023 03:27 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:REFINED SENIOR LIVINGFACILITY NUMBER:
347005577
ADMINISTRATOR:KRIEG, NERRYROSEFACILITY TYPE:
740
ADDRESS:7029 REFINED COURTTELEPHONE:
(916) 334-4910
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 6DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Nerryrose Rimando-Afable, AdministratoTIME COMPLETED:
11:47 AM
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On August 10, 2023 at 9am, (LPA) De Anna Williams-Lyons made an unannounced visit to conduct facilities required annual inspection. LPA Lyons met with Nerryrose Rimando-Afable, administrator whose administrator certificate expires in 2024.
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LPA Rimando completed the Infectious Control Questionnaire with no issues or concerns.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. Fire drills are conducted as required. LPA observed an adequate amount of linens and found the first aid kit to be complete. Hot water temperature measures at 116 degrees F.

LPA reviewed 1 resident records and 1 staff records. Resident files were found to be complete and current. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

In the areas inspected, no citations were issued.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than September 10, 2023.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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