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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700556
Report Date: 04/11/2022
Date Signed: 04/11/2022 03:33:24 PM


Document Has Been Signed on 04/11/2022 03:33 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:DELA PAZ CARE HOMEFACILITY NUMBER:
342700556
ADMINISTRATOR:DELA PAZ, LOURDESFACILITY TYPE:
740
ADDRESS:6712 GREEN ASH CTTELEPHONE:
(916) 599-0477
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:4CENSUS: 4DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Dennis Ababilla, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Dennis Ababilla during today's 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 they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 4 resident rooms, 1 staff room, bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there has been no positive COVID cases at the facility, but have an isolation room and sufficient amount of PPE. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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