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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700531
Report Date: 09/01/2021
Date Signed: 09/01/2021 11:22:39 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:A1 MAGNIFICENT HOMEFACILITY NUMBER:
342700531
ADMINISTRATOR:GAERLAN, LEONIDAFACILITY TYPE:
740
ADDRESS:3311 MISSION AVENUETELEPHONE:
(916) 514-1644
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:5CENSUS: 2DATE:
09/01/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Leonida GaerlanTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 09/01/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Administrator, Leonida Gaerlan and explained the purpose of the visit.

Prior to initiating the annual inspection CCL staff and LPA completed required COVID-19 testing protocols, and self-screened for symptoms of COVID-19. Additionally LPA contacted facility and conducted a pre-screening call prior to inspection. CCL staff and LPA wore the following Personal Protective Equipment (PPE) during today's visit: N95 mask. LPA utilized the facility's self-screening sheet upon arrival.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident rooms, bathrooms, pantry and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed.

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

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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