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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700531
Report Date: 01/29/2021
Date Signed: 01/29/2021 01:27:08 PM

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:A1 MAGNIFICENT HOMEFACILITY NUMBER:
342700531
ADMINISTRATOR:GAERLAN, LEONIDAFACILITY TYPE:
740
ADDRESS:3311 MISSION AVENUETELEPHONE:
(916) 514-1644
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:5CENSUS: 4DATE:
01/29/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Leonida GaerlanTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Melana Llopis and Pheej Cheng, and Local Ombudsman (OMB) Ron Carerra arrived at the facility unannounced on 01/29/2021 at 12:00 PM for a Health and safety check visit. LPAs and OMB met with Administrator, Leonida Gaerlan and explained the purpose of the visit. LPAs observed four (4) residents in care and three (3) staff working. Staff working were observed to be wearing their facemasks.

LPAs, OMB and Administrator toured the facility. Areas inspected include: kitchen, four (4) resident bedrooms and one (1) resident bathroom, food pantry, living and dining area. Facility was found to be clean and in good repair. Residents looked well groomed. LPA Llopis checked food supply and found the the facility has an adequate amount of two (2) day perishable and seven (7) day non-perishables. LPA Llopis checked Personal Protective Equipment (PPE) supply and found the facility had an adequate supply of PPE.

LPA informed Administrator of resources for obtaining PPE as needed.

At 12:15PM, LPA Llopis interviewed resident (R1). LPA found resident to be satisfied with their residency.

At 12:15PM Regional Manager (RM), Alycia Berryman joined the Health and Safety Check visit. RM toured the facility and spoke with Administrator and residents in care. RM informed Administrator of infection control requirements and resources.

At 12:45PM RM, LPAs, and OMB reviewed with Administrator the basic care residents need to be provided while residing in the home.

LPA Llopis to provide to Administrator the PINS relating to COVID-19 via email.
Administrator to send their mitigation plan to LPA Llopis via email.

No deficiencies are being cited as a result of today's visit.

Exit interview conducted with Administrator. Copy of report is being provided to Administrator via email. Administrator is to sign and send a copy of report to Community Care Licensing and keep a signed copy of the report at the facility for their records.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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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