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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700445
Report Date: 05/19/2021
Date Signed: 05/19/2021 02:48:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
092700445
ADMINISTRATOR:DONNA B. COLMENARESFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:64CENSUS: 27DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Melisa Tiburcio (administrator)TIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Konnor Leitzell and Danyle Wolter arrived at the facility unannounced on 05/19/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with Melisa Tiburcio (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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 licensee and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks and gloves.

LPAs and Admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) communal restrooms, kitchen, dining rooms, and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPAs and Admin completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report emailed to admin.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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