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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700012
Report Date: 06/22/2021
Date Signed: 06/22/2021 01:23:20 PM

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:TWIN RIVERS AT NATOMASFACILITY NUMBER:
342700012
ADMINISTRATOR:VADAREVU, SITAFACILITY TYPE:
740
ADDRESS:421 SAN JUAN ROADTELEPHONE:
(916) 216-3058
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:48CENSUS: 36DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Sita Vadarevu, administratorTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 06/22/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator, Sita Vadarevu 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 was screened by facility staff upon entry.

LPA and administrator toured the facility together to ensure health and safety of residents in care, areas inspected include but are not limited to: common areas, four (4) shared resident bedrooms and bathrooms, shower room, kitchen, med room, and outdoor patio area. In the areas toured no immediate health, safety, or personal rights violations were observed.

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

Administrator to send Community Care Licensing (CCL) updated copy of LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, and current liability insurance by 06/29/2021.

In the areas inspected, no deficiencies are being cited.
Exit interview conducted and copy of report to be sent to administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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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