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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700212
Report Date: 11/04/2021
Date Signed: 11/04/2021 02:31:22 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:ROCK CREEK SENIOR CAREFACILITY NUMBER:
312700212
ADMINISTRATOR:BALINT, PAVELFACILITY TYPE:
740
ADDRESS:6408 MENDEZ CREEK CTTELEPHONE:
(916) 899-6298
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 5DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Carmen Balint, AdministratorTIME COMPLETED:
03:00 PM
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On November 4, 2021, Licensing Program Analyst, LPA DeAnna Williams-Lyons arrived unannounced to conduct a required annual inspection. LPA met with Carmen Balint, Administrator and informed her the reason for the visit. Prior to initiating the inspection 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 following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by the front desk personnel upon arrival.

LPA completed the inspection tool questionnaire with Carmen no issues or advisories to report.

LPA observed the following:
This is a 7 bedroom 2 bathroom home. Administrator certificate is valid and expires 8/13/2023. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Smoke alarms and Carbon Monoxide detector are working Hot water temperature measured 107 degrees F.
Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away. There are no bodies of water on the premises.

To continue see 809-C...
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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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: ROCK CREEK SENIOR CARE
FACILITY NUMBER: 312700212
VISIT DATE: 11/04/2021
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As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6. 10

Administrator shall submit the following documents to update the Regional Office files
The following shall be updated and submitted to Community Care Licensing by 12/04/2021:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility
-copy of liability insurance
-updated facility sketch

Exit interview conducted and a copy of this report given to Carmen Balint.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC809 (FAS) - (06/04)
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