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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001429
Report Date: 02/17/2022
Date Signed: 02/17/2022 10:32:47 AM


Document Has Been Signed on 02/17/2022 10:32 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PLACERVILLE HOME CAREFACILITY NUMBER:
306001429
ADMINISTRATOR:MICLEA, RAMONAFACILITY TYPE:
740
ADDRESS:1060 FLAMINGO WAYTELEPHONE:
(562) 477-4343
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 6DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ramona MicleaTIME COMPLETED:
10:47 AM
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Licensing Program Analyst (LPA) Ruth Martinez Conducted an unannounced visit for the purpose of conducting a required inspection visit. LPA was greeted and granted entry by Ramona Miclea, Administrator. LPA met with Administrator and explained the nature of the visit.

LPA began the tour of the facility accompanied by Administrator. The facility currently has 6 residents in care. LPA observed three residents in living room watching television and the remainder of the residents in their bedrooms. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff screens all visitors to the and LPA observed the screening station in the entrance of the facility. Facility keeps documentation in regard to covid for all the staff and residents. LPA observed facility has covid precautionary posting throughout the facility as well as all required department postings. Facility has an active covid-19 prevention plan in place for the safety of residents in care. LPA observed ample supply of emergency food and water in the facility. Facility has a supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces. LPA toured the outside and observed a shaded outside space for resident, area is used for outdoor visitation area as well. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. LPA was advised all staff and residents have had their covid booster shot. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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