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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700253
Report Date: 09/09/2021
Date Signed: 09/09/2021 01:29:36 PM

Document Has Been Signed on 09/09/2021 01:29 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:ITV CARE HOMEFACILITY NUMBER:
312700253
ADMINISTRATOR:QUIPA, KARIZMAFACILITY TYPE:
735
ADDRESS:6064 CRATER LAKE DRIVETELEPHONE:
(916) 742-5232
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 4CENSUS: 4DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Taylor MuzioTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/9/21 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual 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 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: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms,bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator arrived at the facility. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA and Administrator discussed Infection control signs being prominently displayed, questioning all specific symptoms when screening, surgical mask vs cloth masks and Fit testing of N-95s.

LPA requested copies of: resident roster, LIC 500, current Administrator's Certificate and LIC 610E. Documents to be submitted to LPA via email by due date on, 9/23/21.

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

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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