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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005554
Report Date: 05/11/2022
Date Signed: 05/11/2022 10:33:47 AM


Document Has Been Signed on 05/11/2022 10:33 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:EL DORADO HILLS SENIOR CAREFACILITY NUMBER:
097005554
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2904 TAM O'SHANTER DRIVETELEPHONE:
(916) 933-0107
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 6DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Omita Khan, AdministratorTIME COMPLETED:
10:39 AM
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On May 11. 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required Annual Inspection. LPA met with Omit Khan, Administrator, informed her the reason for the visit.

Prior to 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

Omita and LPA conducted the infectious control questionnaire with no issues.

LPA observed the following: Administrators Certificate is valid expiring 8/24/22. Fire extinguishers fully charged. Smoke detector and Carbon Monoxide detector are functional. Facilities temperature measured 74 degrees F. Common areas were clean and in good repair. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. The facility is a 6 bed home All rooms had the required furniture and lighting.

Per California Code of Regulations, Title 22, no deficiencies were observed.

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 in our Regional office.. Administrator shall submit the listed documents to Licensing no later than June 11, 2022.

Exit interview with was conducted and a copy of this report was left with Omita

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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