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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700638
Report Date: 02/28/2023
Date Signed: 02/28/2023 03:51:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/28/2023 03:51 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ESTHER CARE HOMEFACILITY NUMBER:
342700638
ADMINISTRATOR:EGUAVOEN, CHARLESFACILITY TYPE:
740
ADDRESS:4415 ROLLINGROCK WAYTELEPHONE:
(916) 560-3800
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
02/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:EGUAVOEN, CHARLESTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management annual continuation, utilizing the infection control domain. LPA met with caregiver, Donna Marie Neveus and explained the purpose of the visit. Caregiver contacted Administrator immediately.

Today's census is 4. There is (1) resident on hospice services, facility has a hospice waiver of (2).

Administrator arrived to the facility at 2:55 PM. LPA and Administrator conducted a tour of the facility. In areas toured included but not limited to: kitchen, dining room, resident bedrooms, bathroom, staff room, and common areas.

LPA observed the facility to be at 75*. LPA observed the fire extinguisher to be serviced 01/11/2023. LPA observed the facility to have 2+ days of perishable foods and 7+ days of non-perishable foods. LPA observed medication and toxics to be locked and secured but observed the knife drawer was not. LPA observed the up to date Administrator Certificate posted by entrance.

LPA and Administrator discussed the possibility of removing fire doors. LPA stated she will provide Metro Fire contact information to Administrator.

At this time, deficiencies were observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights will be provided to Administrator via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
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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Document Has Been Signed on 02/28/2023 03:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ESTHER CARE HOME
FACILITY NUMBER: 342700638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited

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87309 Storage Space (a) Disinfectants...and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1)Storage areas for... other dangerous weapons shall be locked. Tbhis requirement is not met as evidenced by:
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Knife drawer was locked immediately.
Licensee is to get technical support as Administrator informed LPA ,the facility has been non-operating for some time and will need refreshers on Title 22..
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Based on observation, Licensee did not ensure dangerous items were inaccessible as LPA observed the knife drawer to be unlocked, which poses a potential risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
LIC809 (FAS) - (06/04)
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