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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701102
Report Date: 01/12/2022
Date Signed: 01/12/2022 04:53:40 PM

Document Has Been Signed on 01/12/2022 04:53 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:FOOTHILL LIVING CARE HOMEFACILITY NUMBER:
052701102
ADMINISTRATOR:NGUYEN, ROSAURORAFACILITY TYPE:
735
ADDRESS:8269 SPARROWK ROADTELEPHONE:
(209) 341-9680
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 4CENSUS: 0DATE:
01/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Rosaurora Nguyen, LicenseeTIME COMPLETED:
03:35 PM
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On 01/12/2022, Licensing Program Analysts (LPAs) T.White and M. Jensen arrived announced to conduct a pre-licensing inspection. LPAs met with Licensee, Rosaurora Nguyen and Administrator, Momo Duoa. LPAs explained the purpose of the pre-licensing inspection. Fire clearance is licensed for 4 clients, which 3 ambulatory 1 non- ambulatory.

LPAs toured the facility including but not limited to: physical plant, food service, common area, bedrooms, bathrooms, kitchen and medication storage.

LPAs observed all hallways and passageways to be free of clutter or hazards. LPAs observed kitchen was clean and in good repair. Facility has (7) seven day supply of non-perishables. Client bedrooms were checked and were observed to be adequately furnished. LPAs observed adequate supply of linens. Activity supplies available. LPAs tested water temperature in client's shared bathroom measured at 106.9 and 119.3 degrees F. LPAs observed locked areas where items such as but not limited to, knives, medication, and toxins will be stored inaccessible to clients. LPAs toured the back yard to ensure safety and side of the house to ensure safety.

Smoke detector and carbon monoxide in operating condition during inspection. LPAs observed fully charged fire extinguisher. First aid kit observed to be complete. LPAs observed mitigation plan completed. Emergency Disaster Plan last dated on 08/24/2021.

LPAs discussed the Component III with Licensee and Administrator. Based on observation and interview it appears the facility is ready to be licensed. The report will be forwarded to the centralized application unit for continued processing. No deficiencies cited during inspection.

Exit interview conducted with Licensee and Administrator. A copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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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