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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002890
Report Date: 03/21/2023
Date Signed: 03/21/2023 01:18:06 PM

Document Has Been Signed on 03/21/2023 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:COMPASSION SPRINGS SRFFACILITY NUMBER:
095002890
ADMINISTRATOR:EZEANI, IFEANYIFACILITY TYPE:
772
ADDRESS:4229 TOYAN WAYTELEPHONE:
(916) 870-9676
CITY:DIAMOND SPRINGSSTATE: CAZIP CODE:
95619
CAPACITY: 6CENSUS: DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Program Director Tim HarrisTIME COMPLETED:
01:30 PM
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On 3/21/2023 Licensing Program Analyst (LPA) Lavinia Muscan and Licensing Program Manager (LPM) Laura Munoz, arrived at the facility unannounced to conduct an annual visit using the care tool domain. LPA and LPM met with Program Director, Tim Harris and explained the purpose of the visit. Prior to initiating the visit, LPA and LPM 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. LPA and LPM ensured they used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA, LPM and Program Director toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, outside area and common restrooms. Facility has a 2 day perishable and a 7 day non-perishable amount of food. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA, LPM and Administrator completed the care tool domain and facility was found to be in substantial compliance at this time. Facility has 6.

Administrator agrees to send in LIC500 and liability insurance.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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