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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700763
Report Date: 08/24/2021
Date Signed: 08/24/2021 02:38:46 PM

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:A-1 ELDERLY CAREFACILITY NUMBER:
342700763
ADMINISTRATOR:TIF, ROBERTFACILITY TYPE:
740
ADDRESS:5210 ROBERTSON AVETELEPHONE:
(916) 996-4763
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
08/24/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Simona Tif, caregiver/Co-Administrator TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Simona Tif, caregiver/Co-Administrator. caregiver and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. There are (6) residents at the facility.

LPA observed (3) residents to be watching television in the main room and (3) residents to be resting in their rooms during the inspection. LPA and caregiver toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (2) shared resident bedrooms, (2) private resident bedrooms, (1) resident restroom, (1) staff restroom, kitchen, dining room, and laundry area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food on site. LPA observed PPE supplies on hand to include: N95 masks, gowns, gloves and sanitizers. LPA and caregiver completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 77* F and fire extinguisher was last serviced on 7/14/2021.

LPA requested updated copies of LIC500, LIC610E and copy of liability insurance- to be faxed to the department by 8/31/2021. Current testing protocols discussed for staff and copy of PIN 21-38 issued 8/19/2021 left at facility.

There were no deficiencies cited as a result of todays inspection.
Exit interview conducted with Simona, caregiver, and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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