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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700531
Report Date: 06/30/2022
Date Signed: 06/30/2022 03:07:43 PM


Document Has Been Signed on 06/30/2022 03:07 PM - 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, 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) 335-5831
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:5CENSUS: 3DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leonida GaerlanTIME COMPLETED:
03:20 PM
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On 6/30/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced 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, 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: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

LPA observed the interior of the facility. LPA observed (3) residents present at the facility. LPA was informed by residents that the facility "allows their dignity to grow". LPA observed all areas to be clean, in good repair and to be odor free and the bathrooms and kitchen to have paper towels, soap, trash cans with lids and Covid posters. LPA observed multiple Covid posters and hand sanitizers throughout and required postings displayed. Discussed vaccination protocols of residents and staff and visitation protocols in place. LPA and Administrator completed the Infection Control Domain regarding Covid protocols in place. LPA observed the Administrator Certificates (Estrella Shortey and Leonida B. Gaerlan) to be up to date. LPA reviewed (2) resident's file.

LPA requested Administrator to send a copy of the current liability insurance be emailed to CCLD by
Friday 7/8/2022.

There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: A1 MAGNIFICENT HOME
FACILITY NUMBER: 342700531
VISIT DATE: 06/30/2022
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Administrator informed LPA that an Incident Report was submitted regarding a conflict between two residents and one fell. Administrator informed LPA that EMS and family were informed. Administrator inquired what can she do if a resident refused medical attention. LPA responded that the facility should practice Medical Refusal Form for residents.

Administrator asked LPA what is the protocol for residents with EtOH diagnosis. LPA informed Administrator she will ask her Licensing Program Manager and email a response.

LPA advised Administrator to get LIC 602A to be updated for residents.

Administrator asked what is the Department's practice for medical marijuana, LPA informed Administrator she will get a confirmation on this response and notify Administrator as soon as possible.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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