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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001403
Report Date: 09/14/2022
Date Signed: 09/14/2022 01:18:49 PM

Document Has Been Signed on 09/14/2022 01:18 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,
, CA
FACILITY NAME:CHRISTAL VIEW CARE HOMEFACILITY NUMBER:
045001403
ADMINISTRATOR:CLARITA DIZONFACILITY TYPE:
735
ADDRESS:3074 GAWTHORNE AVENUETELEPHONE:
(530) 532-6356
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 6CENSUS: 4DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Zosima Mulato-Dizon - Direct Care StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace arrived at the facility unannounced to conduct a Required -1 Year Inspection utilizing the infection control domain, LPA met with care staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask, gloves. Additionally, LPA Wallace was screened facility staff.

LPA Wallace and direct care staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, three (3) bathrooms, kitchen, common areas, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace completed the infection control domain and facility was found to be in substantial compliance at this time. LPA observed the smoke/monoxide alarms to be in working order and the fire extinguishers are fully charged which expires 9/8/2023. Facility is conducting quarterly fire drills and the last one was conducted 8/16/2022. The hot water measured 109.4*F which is within the required range of 105-120*F.

LPA reviewed 2 of 4 resident records. LPA reviewed 2 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed current first aid certificates and 1 staff is missing current first aid certificate.

LPA Wallace completed infection control domain and observed no issues or concerns.


One deficiency cited today according to California Code of regulations, Title 22.

Exit interview conducted with direct care staff. A copy of reports and appeal rights were given to direct care staff.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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Document Has Been Signed on 09/14/2022 01:18 PM - It Cannot Be Edited


Created By: Ruth Wallace On 09/14/2022 at 01:06 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
,
, CA

FACILITY NAME: CHRISTAL VIEW CARE HOME
FACILITY NUMBER: 045001403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation,the licensee did not comply with the section cited above in Staff #1's first aid certificate expired 9/8/202,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Staff #1's first aid certificate expired 9/8/2022. Licensee agrees to have new first aid course completed by Plan of Correction Date 9/21/2022. Licensee will email copy to Licensing Program Analyst Laura Munoz.
laura.munoz@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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