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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701102
Report Date: 02/28/2024
Date Signed: 02/28/2024 11:15:21 AM

Document Has Been Signed on 02/28/2024 11:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 1DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rosauraora Nguyen and Karen Puente and Phoenix Lee Nguyen TIME COMPLETED:
11:30 AM
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On 02/28/2024 at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Rosauraora Nguyen and Karen Puente and Phoenix Lee Nguyen and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires on 10/14/2024. The facility is licensed for 4 ambulatory clients, of which 1 may be non-ambulatory. There is currently 1 client who reside at this facility.

The LPA Martinez toured the facility with Rosauraora Nguyen and Karen Puente on 02/28/2024 at 10:20 AM.

LPA Martinez reviewed 1 client file and 2 staff files, and all files were complete. LPA Martinez reviewed 1 Medication Administration Record (MAR), and the MAR was maintained. The water temperature measured at 118 degrees. The facility temperature measured at 70 degrees. The fire extinguishers, smoke detectors. and carbon detectors are in good repair. The last fire drill was February 2024. The exterior of the home is clear of debris, and emergency exit gate is in good repair. The facility first aid kit is complete. The facility is sanitary and clean and furnished. Resident bedrooms are furnished and sanitary. The facility bathrooms are sanitary. The facility kitchen is sanitary, and the facility has an adequate food supply. The facility also has emergency water kit.

Based on today's annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


An exit interview was conducted, and a copy of this report was given to the facility at the end of the visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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