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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700098
Report Date: 04/19/2022
Date Signed: 04/19/2022 06:21:02 PM


Document Has Been Signed on 04/19/2022 06:21 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:CARMICHAEL SENIOR CAREFACILITY NUMBER:
342700098
ADMINISTRATOR:DIZON, MARIA SUSIE VFACILITY TYPE:
740
ADDRESS:5208 FAIR OAKS BLVDTELEPHONE:
(916) 973-9533
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
04/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Albert Roma, caregiver, Shirley Dizon, Licensee and Suzanne Dizon, caregiver TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Albert Roma, caregiver, who contacted Administrator, Shirley Dizon, who, arrived shortly to the facility at approximately 3:00 pm with Suzanne Dizon, caregiver. LPA explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. Facility currently has (6) residents and (0) residents are on hospice.

LPA assisted Licensee, Shirley, pay balance in full on past due annual fees. Licensee stated that there have been accounting discrepancies previously between this facility and related facilities and payments are on auto-pay through the bank. LPA reviewed billing and payment history on this account and related facilities and it appears that payments are applied to the oldest balance first and subsequent late charges are made. LPA provided balance and PIN information to Licensee for each facility. Licensee to go on-line and pay balance in full on related facilities to clear balances. LPA observed balance to be paid in full on this facility during today's inspection.

LPA and caregiver toured the facility to ensure the health and safety of the residents. LPA observed all residents to be in their rooms resting and no health and safety hazards to be observed.

LPA and Administrator discussed the vaccination status of residents and staff and testing protocols in place

There are no deficiencies cited in today's report; however, a technical advisory note is being issued.

Exit interview. Copy of report to be e-mailed to Licensee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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