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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701102
Report Date: 03/02/2023
Date Signed: 03/02/2023 11:04:07 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/02/2023 11:04 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: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:
03/02/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Rosaurora NguyenTIME COMPLETED:
11:15 AM
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On 3/2/23 at 9:40am Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a required 1 year annual inspection. LPA Jensen met with Licensee Rosaurora Nguyen and explained the purpose of today's visit. This visit was scheduled as the facility has not admitted it's first resident as of yet.

LPA Jensen toured the facility and grounds. The grounds were observed to be maintained and free of debris. All paths were clear of obstruction. There is adequate outdoor furniture and shade available on the grounds. There are no bodies of water on the property.

The facility has 3 bedrooms and 3 bathrooms. 2 bedrooms are single occupancy and 1 bedroom is double occupancy. All bedrooms were observed to have night stands, lamps, dressers and chairs. The facility has lighting throughout. LPA Jensen observed numerous activities available for resident engagement. Perishable food is labeled with expiration dates. An emergency supply of food and water is kept on site. Emergency lighting is also available. The first aid kit was observed to be complete with scissors, tweezers, thermometer, various wound dressings and manual. The fire extinguisher was last serviced in February of 2023 and is in compliance. The carbon monoxide detector was determined to be in good working order.

All Knives, medications, toiletries and cleaning supplies were observed to be locked and inaccessible to residents in care. The temperature in the bathrooms was determined within the required regulatory range of 105 to 120 degrees. There is non-slip flooring in the bathroom showers. The facility has an adequate supply of linens and bedding available. All rooms were observed to be sanitary and the facility was free of odor. The LIC 610 was reviewed.

This facility is in substantial compliance. An exit interview was conducted and a copy of this report was given to the Licensee.


SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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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