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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700560
Report Date: 06/15/2022
Date Signed: 06/15/2022 10:03:04 AM

Document Has Been Signed on 06/15/2022 10:03 AM - 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:FRIENDLY CARE HOME IIFACILITY NUMBER:
342700560
ADMINISTRATOR:JURAVLE, CLAUDIA CAMELIAFACILITY TYPE:
740
ADDRESS:9009 PLUM BLOSSOM CTTELEPHONE:
(916) 792-6371
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 6DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Camelia Juravle, AdministratorTIME COMPLETED:
10:30 AM
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On June 15, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived to conduct a 1 year required annual inspection. LPA met with and explained the reason for the visit. Prior to initiating the visit, 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, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by staff.
Camellia and LPA completed the infectious Control questionnaire with no issues.
.
LPA conducted a walk-through of the facility to ensure compliance with Title 22 regulations. This is a 10 bedroom home with 4 bedrooms.Furniture and furnishings were observed to be sufficient and in good repair. LPA inspected the fire extinguisher and it is in good condition.

Per Californian Cod of Regulations, no citations were issued.

Administrator submitted the Infectious Control Plan to LPA

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than July 15, 2022.

An exit interview was conducted and a copy of this report was given to .Camelia.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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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