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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700341
Report Date: 01/10/2022
Date Signed: 01/10/2022 10:06:22 AM

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: 0DATE:
01/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Daniel Gonzales, Administrator/LicenseeTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a case management visit. LPA met with Administrator/Licensee Daniel Gonzales during today's 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

Licensee is closing the facility and has moved all residents out of the facility. Licensee continues to live on the other side of the home. LPA toured the facility and observed all residents have moved. LPA received license from licensee. LPA will close facility in CCL system.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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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