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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700253
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:49:05 PM

Document Has Been Signed on 12/29/2022 04:49 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:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:CaregiverTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 12/29/22 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 the Department's required COVID-19 testing protocolst. 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. Administrator was unavailable to attend

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, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and caregiver completed the a review of infection control and facility was found to be in substantial compliance at this time.

LPA and caregivers discussed Fit testing of N-95s to be continued for all staff, more robust visitor screening, thorough surface disinfecting, Posting of Ombudsman and CCL complaint poster (22x33 in) and that staff are all trained on the Infection Control Plan. LPA also advised that when physicians are consulted that there is a mechanism for staff being informed of the result.

LPA requested copies of: LIC 500, client roster.

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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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