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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700775
Report Date: 08/13/2021
Date Signed: 08/13/2021 10:38:45 AM

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:FOLSOM CAREFACILITY NUMBER:
342700775
ADMINISTRATOR:ABELARDO, BERYLFACILITY TYPE:
740
ADDRESS:148 STONEY HILL DRIVETELEPHONE:
(916) 983-9988
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:5CENSUS: 5DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Beryl Abelardo (Administrator)TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 8/13/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Beryl Abelardo (Admin) and Mel Abelardo (Staff) and explained the purpose of the visit. Prior to initiating the annual 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by admin and answers were documented in their visitor screening log.

LPA and admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) of five (5) resident bedrooms, two (2) of two (2) bathrooms, one (1) of one (1) staff room, garage, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time. LPA is requesting the following documents to be submitted via email konnor.leitzell@dss.ca.gov by COB August 8/25/2021; Personnel Report (LIC500); Designation of Administrative Responsibility (LIC308); Affidavit Regarding Resident Cash Resources (LIC400); Surety Bond (LIC 402); Administrator certificate ; Partnership Agreement; Articles of Incorporation; Disaster Plan (LIC610e); Control of Property; Limited Liability Insurance; and Neighborhood Complaint Policy.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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