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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700194
Report Date: 10/17/2023
Date Signed: 10/17/2023 12:08:12 PM


Document Has Been Signed on 10/17/2023 12:08 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:VERA, NAZARINA DETIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady made an unannounced visit to this facility to conduct an annual inspection. 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 certificate 6027605740 expired on 8/7/2023. Administrator applied for new certificate 7/1/2023. The facility is licensed for six non-ambulatory residents. There are currently 6 residents who reside at this facility, and the facility has an approved hospice waiver for 6.

LPA Ivey Canady toured the facility with Nazarina Vera. LPA requested and reviewed 2 staff and 2 personnel files during today's visit.

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 fire extinguisher 7/2024, 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 emailed to administrator due to printer malfunction.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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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