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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700757
Report Date: 05/12/2021
Date Signed: 05/12/2021 01:41:15 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:ROCKLIN CARE HOMEFACILITY NUMBER:
312700757
ADMINISTRATOR:MAGDA, MARYFACILITY TYPE:
740
ADDRESS:6459 SONORA PASS WAYTELEPHONE:
(916) 872-1537
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 2DATE:
05/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:David Magda, administratorTIME COMPLETED:
01:50 PM
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Licensing Program Analysts (LPAs) Wolter and Leitzell arrived at the facility unannounced on 05/12/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with staff, David Magda and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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 contacted licensee and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPAs were screened by facility staff upon entering the facility.

LPAs and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and staff completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.

Staff to send in updated copy of LIC 308 - Designation of Facility Responsibility and current copy of Liability Insurance to Community Care Licensing by 05/19/2021.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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