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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701016
Report Date: 08/24/2021
Date Signed: 08/24/2021 12:14:49 PM

Document Has Been Signed on 08/24/2021 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:POPPY LANE CARE HOMEFACILITY NUMBER:
032701016
ADMINISTRATOR:COCJIN, AARONFACILITY TYPE:
735
ADDRESS:100 POPPY LANETELEPHONE:
(559) 360-9058
CITY:IONESTATE: CAZIP CODE:
95640
CAPACITY: 4CENSUS: DATE:
08/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Aaron CocjinTIME COMPLETED:
01:00 PM
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On 08/24/21 at 11:00 AM, Licensing Program Analyst (LPA) Christina Valerio arrived at the facility to conduct an announced pre-licensing visit. LPA Valerio introduce herself and discussed the elements of the pre-licensing visit with Administrator Aaron Cocjin. LPA Valerio was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility.
 
The facility has a fire clearance for a capacity of 4 (2 ambulatory and 2 non-ambulatory residents).  Observed there are no residents at this time. Arvin will be the designated Administrator for the facility, Administrator Certification Expiration 12/07/2021. LPA Valerio reviewed and approved LIC 808 mitigation plan during the visit.
 
LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed no health and safety concerns. The facility is a 4 bedroom, 2 bath with 1 family living room, dining room, laundry room, kitchen, garage, and exterior area. The exterior area has a shaded sitting area with a cement walkway. Residents will have access to all areas except the garage, medication storage area, and locked cabinet storage for cleaning supplies and sharps.
 
LPA observed the area where the staff and resident files will be locked and readily available for review. Emergency disaster plan and necessary COVID-19 questionnaire. Facility will keep a 30-day supply of face shields, gowns, N95s, surgical masks, hand sanitizers, and sanitizing wipes in the closet in the kitchen and the garage. First aid kits and emergency supply of food were observed to be fully stocked. LPAs observed no obstruction of emergency exits inside or outside of facility.


Continue on LIC 809 - C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: POPPY LANE CARE HOME
FACILITY NUMBER: 032701016
VISIT DATE: 08/24/2021
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Continued from LIC 809...

LPA’s observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, and office. Resident bedrooms observed to have necessary furniture. Resident bedrooms are furnished with a bed, chair, night stand, personal dresser, and extra closet space. Resident bathrooms observed to have non-skid mats, soap, paper towels, and closed lid garbage cans. All emergency exits have appropriate signage. Cleaning supplies were secured and locked in garage. LPA observed smoke detectors and carbon monoxide detectors were noted and functioning properly. LPA Valerio and Administrator Aaron observed the hot water temperature in resident's bathroom at 110.3*F within regulatory range of 105 *F and 120 *F. LPA’s observed area where food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days will be maintained on the premises.

LPA Valerio observed fire extinguisher in place outside of kitchen area and fully charged, last inspected on 12/17/2020.

Pre-Licensing is complete and this facility has no deficiencies. A Component III was completed at this time with the Applicant. Administrator Aaron had no further questions. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.













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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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