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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700194
Report Date: 09/08/2022
Date Signed: 09/08/2022 10:04:26 AM


Document Has Been Signed on 09/08/2022 10:04 AM - 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, 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:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nazarina Vera TIME COMPLETED:
10:16 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/08/2022 at 9:00 AM. LPA met with Nazarina Vera and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for six non-ambulatory residents. There are currently 5 residents who reside at this facility, and the facility has an approved hospice waiver for 6.

LPA Martinez toured the facility with Nazarina Vera on 09/08/2022 at 9:00 AM.

The facility has submitted a Covid-19 mitigation plan and Infection Control plan. The facility has one main screening entry point, and conducts daily staff, visitors, and resident screening checks. The facility has a 30 day supply of PPE, and conducts daily disinfecting cleaning. The facility has Covid-19 postings throughout the facility.

The fire extinguisher, smoke detectors, and carbon detectors are in good repair. The facility has a first aid kit and medications are stored in a locked cabinet. The facility has an adequate supply of food, and the kitchen was sanitary. The resident bedrooms were furnished and in good repair. The exterior of the facility is clear of debris, and the emergency exit gate is in good repair.

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.


An 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: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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