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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002873
Report Date: 03/22/2022
Date Signed: 03/22/2022 10:40:18 AM

Document Has Been Signed on 03/22/2022 10:40 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CIRBY RANCH SRFFACILITY NUMBER:
315002873
ADMINISTRATOR:EZEANI, IFEANYIFACILITY TYPE:
772
ADDRESS:1085 SANDRINGHAM WAYTELEPHONE:
(916) 870-9676
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 0DATE:
03/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ifeanyi EzeaniTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility on 3/22/2022 to conduct a Pre-Licensing Inspection utilizing the inspection tool. LPA met with Administrator, Ifeanyi Ezeani, and explained the purpose of the visit. Prior to initiating the Pre-Licensing 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 LPA completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. LPA observed COVID-19 signages.

LPA toured the interior and exterior of the facility together with Administrator. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, laundry room, kitchen, garage, and backyard. There is a spare bedroom that will be utilize for COVID-19 purposes. LPA observed locked cabinet in the kitchen where knives/sharps will be locked. Toxic and cleaning supplies will be locked in the laundry room. LPA observed the required furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. Hot water temperature was measured in residents' bathrooms at 115 degrees Fahrenheit. First aid kit was completed and located in the office. LPA observed centrally stored medication areas to be locked in the office along with clients' files. LPA observed fire extinguisher in the kitchen. LPA observed fire detectors and carbon monoxide.

Component III presentation conducted with Administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with Administrator. A copy of this report was provided to the facility via email.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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