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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004845
Report Date: 02/17/2022
Date Signed: 02/17/2022 12:14:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/17/2022 12:14 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:AAA HOME CAREFACILITY NUMBER:
317004845
ADMINISTRATOR:FLORES, FRANKLYNFACILITY TYPE:
740
ADDRESS:6268 GRAND CANYON DR.TELEPHONE:
(916) 773-1207
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:5CENSUS: 5DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Franklyn FloresTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/17/22 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 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. Administrator arrived to assist with the visit.

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. LPA and designee completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA advised the following: locks to cabinets in the kitchen where harmful products are stored, more robust symptom screening, and ensure all staff have fit tested N-95s.
LPA and administrator discussed the training, documentation and record keeping for incontinence care plans and wound care and process for medication dispensing if pour by person other that dispensing.

LPA requested: Administrator's Certificate and Liability Insurance copies when renewed.

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

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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