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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700392
Report Date: 09/10/2021
Date Signed: 09/10/2021 09:48:07 AM

Document Has Been Signed on 09/10/2021 09:48 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:SOLSIE, LLCFACILITY NUMBER:
342700392
ADMINISTRATOR:SOL-SIERRAS, CAMINA FRICIAFACILITY TYPE:
735
ADDRESS:10064 SCHULER RANCH RDTELEPHONE:
(209) 877-4319
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 4DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Camina Sol-SierrasTIME COMPLETED:
10:15 AM
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On 9/10/2021 at 8:45 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Upon LPAs arrival, Caregiver Rebecca Sol was present at facility and contacted Administrator, Camina Sol-Sierras who arrived a bit later. LPA met with Camina Sol-Sierras and explained the purpose of the visit.

Administrator holds current certification #6046805735 and expires on 2/6/2022. The facility is licensed to serve up to (4) four ambulatory clients only. There are currently 4 clients who reside at this facility. LPA toured the facility with Administrator Camina Sol-Sierras on 9/10/2021 at 9:00 am.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 113.4 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SOLSIE, LLC
FACILITY NUMBER: 342700392
VISIT DATE: 09/10/2021
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LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool.

The facility mitigation plan was submitted to CCLD, and it was approved on 3/17/2021. Facility has routine symptom screening checks for clients, staff, and visitors. The facility has a symptom check binder for staff, clients, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)
(7) Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview held with Administrator Camina Sol-Sierras and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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