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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002882
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:55:57 PM


Document Has Been Signed on 02/23/2023 03:55 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:NADIA'S CARE HOME LLCFACILITY NUMBER:
315002882
ADMINISTRATOR:NADEJA NICULAIFACILITY TYPE:
740
ADDRESS:2728 WESTVIEW DRIVETELEPHONE:
(916) 755-9575
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 6DATE:
02/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Nadeja NiculaiTIME COMPLETED:
01:30 PM
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LPA Parks arrived on Thursday February 23, 2023 to conduct a case management visit. Prior to the visit, 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; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

This is a follow up visit for an incident that occurred on 2/18/2023. As R1 was sitting in their recliner, R1 then attempted to stand up independently and fell on the floor. R1 was transferred to the bed where the Licensee did a body exam. No pain, bruising, or skin tears were observed. Later, R1 complained of pain around the right hip. Hospice and DPOA were called. 911 was called and R1 was transferred to the hospital where they were diagnosed with a hip fracture.

LPA interviewed S1 and Licensee who were present during the incident. LPA obtained the following documents: R1's physicians report, care plan, and current medication list.

No deficiencies were cited. Exit interview conducted.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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