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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700194
Report Date: 09/22/2021
Date Signed: 09/22/2021 09:36:10 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NORRIS SENIOR HOMEFACILITY NUMBER:
342700194
ADMINISTRATOR:VERA, NAZARINA DEFACILITY TYPE:
740
ADDRESS:4184 ENGLE ROADTELEPHONE:
(916) 571-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Nazarina Devera TIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 09/22/2021.LPA Martinez met with Nazarina Devera and explained the purpose of this visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

The LPA Martinez toured the facility with Jay Legacion on 09/22/2021 at 8:55 AM.

The facility has submitted a mitigation plan to CCLD. The mitigation plan has been approved by CCLD. The facility has one central entry point for universal entry screening. All visitors, staff, and essential workers are screened for Covid-19 symptoms. Moreover, hand hygiene postings are posted throughout the facility. The facility has hand sanitizer dispensers throughout the facility.

The facility conducts hourly disinfection cleaning. Facility common areas are furnished and furniture is spaced 6 feet apart. The facility exterior patio is clear of derbies.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


Exit interview was held, and a copy of this report was given to the facility at the end of this visit.



SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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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