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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700396
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:00:45 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:LOVE & CARE FOR ELDER IIFACILITY NUMBER:
342700396
ADMINISTRATOR:SUIUGAN, ELIZABETHFACILITY TYPE:
740
ADDRESS:7990 COOK RIOLO RDTELEPHONE:
(916) 723-2912
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 4DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Elizabeth SuiuganTIME COMPLETED:
12:15 PM
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LPA Lusby arrived on Monday December 6, 2021 to conduct the annual inspection. Prior to the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: kitchen, backyard, bedrooms (4) and bathrooms (3). In the areas toured no immediate health, safety, or personal rights violations were observed.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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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