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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700341
Report Date: 11/18/2021
Date Signed: 11/18/2021 11:50:11 AM

Document Has Been Signed on 11/18/2021 11:50 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MAGIC MOMENTS ELDER CAREFACILITY NUMBER:
342700341
ADMINISTRATOR:GONZALES, DANIELFACILITY TYPE:
740
ADDRESS:8500 ROBIE WAYTELEPHONE:
(916) 721-4721
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 2DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Daniel Gonzales, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Daniel Gonzales during today's inspection. 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff upon entering the facility.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, staff area, 2 bathrooms, kitchen, common living spaces, and the backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there has been no positive COVID cases at the facility, but have sufficient amount of PPE and supplies. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time.

Administrator to send into CCL a copy of updated administrator certificate, liability insurance, and LIC308.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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