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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700556
Report Date: 04/05/2023
Date Signed: 04/05/2023 03:35:00 PM


Document Has Been Signed on 04/05/2023 03:35 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:DELA PAZ CARE HOMEFACILITY NUMBER:
342700556
ADMINISTRATOR:DELA PAZ, LOURDESFACILITY TYPE:
740
ADDRESS:6712 GREEN ASH CTTELEPHONE:
(916) 560-3232
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:4CENSUS: 4DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dennis Abadilla and Lourdes dela Paz, Administrators TIME COMPLETED:
03:35 PM
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Licensing Program Analysts (LPA's) Sabrina Calzada and Ivan Avila arrived unannounced to conduct an annual inspection. LPA's met with Edgar Chico, DSP, who contacted Administrators by phone. Administrator Dennis Abadilla and Lourdes dela Paz arrived at approximately 12:45 pm. The facility is a level 4--I home, vendorized by Alta California Regional Center, and is licensed for (4) non-ambulatory clients. LPA's observed (3) clients present at the start of the inspection and (1) client return from day program later.

LPA's and Administrators toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, staff room, (2) resident bathrooms, kitchen, office, laundry area and garage. LPA's observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA's observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps to be locked. LPA's observed locked toxins in the laundry area and locked medications in the office. LPA's observed sufficient PPE/emergency supplies in the garage. The inside temperature measured 68*F. The fire extinguisher was last serviced on 9/15/22 and smoke/monoxide alarms were in working order. LPA's observed (2) unlocked gates from the inside back patio and patio area with seating. Outside sheds are for storage. LPA's reviewed (2) of (4) client files and found them to contain current documentation. LPA's reviewed P&I funds for (1) client and found it to be accurate and confirmed a surety bond was renewed in Feb 2023. LPA's compared ordered medication to medication being given for (1) client and found no discrepancies. LPA's reviewed (2) staff files and found them to contain current First Aid/CPR training and documentation of monthly staff trainings. Adult Administrator Certificates #6041507740- exp 7/12/24. LPA's reviewed the Infection Control Plan and found it to be complete for approval. Hot water measured 110*F in the kitchen. LPA's observed all required postings to be posted. Emergency evacuation supplies and PPE on hand. LPA requested an updated copy of the LIC308. LIC500 be sent to CCLD by 4/12/23. There are no deficiencies issued during today's inspection. Exit interview. Copy of report emailed to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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