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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700321
Report Date: 06/07/2021
Date Signed: 06/07/2021 04:31:13 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:A LOVING AND DIVINE HOME CAREFACILITY NUMBER:
342700321
ADMINISTRATOR:IVANCICH, LARRYFACILITY TYPE:
740
ADDRESS:304 OAK CANYON WAYTELEPHONE:
(916) 945-0259
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 6DATE:
06/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Russelle and Curtis Robinson, Arminder TahkarTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 06/07/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Facility Representatives Russelle and Curtis Robinson, and Arminder Tahkar and explained the purpose of the visit. Prior to initiating the prelicensing visit, 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; contacted Facility Representative 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: surgical mask. Additionally, LPA was screened by Curtis Robinson.

This facility has six private resident rooms and two caregiver rooms. The main entrance opens into a small foyer. To the left of the main entrance there is a small office area and kitchen. Past the kitchen and office area there is a door leading to a hallway that has the laundry area, door leading to the garage and one caregiver room, a caregiver room, a full common bathroom, and two resident rooms that have exits to the outside. To the right of the main entrance is another door that leads to a hallway that has four private resident rooms and a full common bathroom. Across the main entrance is the main sitting area, dining area, and kitchen. There are locked cabinets for sharp knives and medications. The backyard was inspected. There is a gate on the same side as the garage. There is a raised wood patio that is has one area covered and the patio has ramps. There is a pool with a five foot tall wrought iron fence surrounding it and is locked.

Several topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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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