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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311224
Report Date: 05/12/2022
Date Signed: 05/12/2022 02:19:16 PM

Document Has Been Signed on 05/12/2022 02:19 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:SEGOVIA'S CARE HOME #1FACILITY NUMBER:
340311224
ADMINISTRATOR:SEGOVIA, NIMFAFACILITY TYPE:
735
ADDRESS:7118 BONITA WAYTELEPHONE:
(916) 722-3789
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 5DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Nimfa Segovia, Administrator TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with administrator Nimfa Segovia during today's 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 4 client rooms, bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there has been no positive COVID cases at the facility, but have an isolation room and sufficient amount of PPE. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time.

Administrator to send into CCL administrator certificate, LIC402, LIC400, and fire inspection.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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