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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701016
Report Date: 08/30/2022
Date Signed: 08/30/2022 11:14:33 AM

Document Has Been Signed on 08/30/2022 11:14 AM - 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: 3DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Aaron Cocjin TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced herself, explained the purpose of the visit, and was met by facility staff.
 
LPA conducted the infection control domain tool. LPA reviewed the infection control plans: original copy and updated copy for Monkey Pox. The infection control plans met department requirements. LPA observed the facility to have hand washing signs posted at the front door and throughout the facility. The facility has a designated infection control lead, and the emergency plan is posted at the front door.
 
LPA observed the temperature inside the facility was measured at 76*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 106.2*F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. An emergency supply of foods were observed. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 11/17/2021.
 
Per California Code of Regulations, no deficiencies were observed during this visit. An exit interview was held with Administrator Aaron, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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