<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700009
Report Date: 06/23/2021
Date Signed: 06/23/2021 11:50:15 AM

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:ARCELY J PUA HOMECAREFACILITY NUMBER:
342700009
ADMINISTRATOR:PUA, ARCELY JFACILITY TYPE:
740
ADDRESS:914 DENSMORE WAYTELEPHONE:
(916) 300-5286
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 5DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Arcely J Pua (Admin)TIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 6/23/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Arcely Pua (Admin) 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; 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 Masks. Additionally, LPA was screened by Admin and documented in their visitor screening log.

LPA and admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) of five (5) resident bedrooms, two (2) of two (2) bathrooms, staff break room, kitchen, garage, laundry room and backyard. LPA viewed facilities food and PPE supply to be sufficient. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Admin completed the infection control domain and facility was found to be in substantial compliance at this time.

At this time, LPA is requesting the following documents to be provided via fax at (916) 263-4744 to Community Care Licensing (CCL) by COB 7/2/2021: Designation of Administrative Responsibility (LIC308); Personnel Report (LIC500); Neighborhood Complaint Policy. LPA was informed that Admin certificate expired 4/2021 but has completed all requirements for Admin Certificate renewal, but has not received the printed document as of yet. Admin will provide administrative certificate once received.

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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1