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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097004652
Report Date: 06/06/2022
Date Signed: 06/06/2022 01:10:51 PM

Document Has Been Signed on 06/06/2022 01:10 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CONCEPCION HOMEFACILITY NUMBER:
097004652
ADMINISTRATOR:CONCEPCION, FIDELINAFACILITY TYPE:
735
ADDRESS:409 CRANSTON COURTTELEPHONE:
(916) 941-1507
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 3CENSUS: 3DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Reuben Concepcion, Co-AdministratorTIME COMPLETED:
01:30 PM
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On June 6, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived to conduct a 1 year required annual inspection. LPA met with Reuben Concepcion Co-Administrator, and explained the reason for the visit. Prior to initiating the visit, LPA 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, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the Personal Protective Equipment (PPE) was worn: mask. The Administrator Certificate expires 5/23/2023.
Reuben and LPA completed the Infectious Control Questionnaire with no issues to report.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. The home was 67 degrees F.

The facility is a one story home with 5 bedrooms. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. All rooms had the required items of furniture. Bathrooms were sanitary and odorless and consisted of grab bars and non-skid mats. The sinks and toilets operate properly.



To continue see 809-C...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CONCEPCION HOME
FACILITY NUMBER: 097004652
VISIT DATE: 06/06/2022
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First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence is in good repair. It is recommended that the shrubs are trimmed in the backyard.

There’s a centralized storage area for resident’s medication. Medications were locked away in a room.. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than July 6. 2022.

An exit interview was conducted and a copy of this report was given to Reuben.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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