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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005183
Report Date: 01/04/2023
Date Signed: 01/13/2023 07:38:17 AM


Document Has Been Signed on 01/13/2023 07:38 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:FOUNTAINS SENIOR CARE, THEFACILITY NUMBER:
317005183
ADMINISTRATOR:MACIUCA, ESTERAFACILITY TYPE:
740
ADDRESS:231 CURRY COURTTELEPHONE:
(916) 899-5755
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 5DATE:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Esrera MaciucaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/4/23 to conduct a Required-1 Year Inspection referencing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required the Department's COVID-19 testing protocols. Risk assessment performed upon arrival LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA prompted caregiver to screen visitors 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 arrived to assist.

LPA toured the facility together with staff to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator arrived at the facility. LPA and licensee completed the infection control domain and facility was found to be in substantial compliance at this time. Upon arrival, LPA observed staff to not be wearing surgical mask. LPA prompted staff who complied to wear mask. Clean safe and sanitary with required food.

LPA advised Administrator associate all staff from other of their facilities to be associated to all if they will work at other of their facilities. Infection control and emergency measures discussed. Training will continue for infection control procedures. LPA alerted them to PIN 22-13.

LPA requested resident roster, LIC 500 and liability insurance be submitted.

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: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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