342700792-8-12-2020-27-AS-KLEL-BSF2HP-20200812172503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700792
Report Date: 08/12/2020
Date Signed: 08/12/2020 05:25:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	AMERICAN RIVER RESIDENTIAL CARE, LLC		FACILITY NUMBER:	342700792
ADMINISTRATOR:	SU, JOLENE SOI		FACILITY TYPE:	740
ADDRESS:	124 HILLSWOOD DRIVE		TELEPHONE:	(916) 508-0543
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Jolene Su (Applicant)		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Konnor Leitzell, LPA Michael Hood and LPA Sabrina Calzada conducted a scheduled pre-licensing inspection via tele-visit on 8/12/2020. Due to COVID-19 and precautionary measures, this inspection was done over Google Duo. This is a change in ownership and currently has five (5) residents living in the facility. LPAs and Applicant toured the interior and exterior of the facility, viewing the common areas, residents bedrooms, bathroom, kitchen, garage, and medroom. LPAs observed the facility to be clean, in good repair and to have sufficient furniture in common areas, both interior and exterior. LPAs observed sufficient lighting throughout the facility, and had wall lights for night time from residents rooms to the central bathrooms. LPAs viewed the backyard and patio, noted that all fences to bodies of water were closed and locked with a key lock. LPAs viewed the thermometer for the running water at 110 degrees, and the refrigerator reading 34 degrees and the freezer reading 0 degrees. Facility had a 7+ day supply of non-perishables and an alarm sounding for when exterior doors are opened and closed. When viewing the living room, many activities were seen available. Administrator stated more personalized activities will be provided to residents when known. LPA's saw the fire alarms and Co2 detectors were in working condition by the administrator testing them. LPA's viewed the fire extinguisher was last serviced in June 2019, Current licensee stated will get checked first thing tomorrow morning 8/13/2020. When touring the kitchen and medication room, administrator showed LPAs the locked cabinets for the sharps, detergents. When viewing kitchen, LPA noticed child lock being used for detergents. Licensee removed them from the location and placed them in separate locked room. LPAs checked and ensured the facility had sufficient dishes, flatware, cooking pans, and linens. LPAs viewed a complete first aid kit. In the locked medications room LPA's viewed where staff files, resident files, and residents medications. There is currently a working land line in the facility that was viewed by LPAs.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AMERICAN RIVER RESIDENTIAL CARE, LLC	FACILITY NUMBER: 342700792
	VISIT DATE: 08/12/2020

NARRATIVE

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LPAs observed the following posted at the facility: Resident Personal Rights, Rights of Resident/Family Councils, See Something Say Something, the Facility Sketch with evacuation routes, Ombudsman poster, and the non-discrimination clause.

Facility has grab bars at the toilets, and showers along with non-skid floor mats.

Comp III was conducted during today's inspection. ** Also, COVID-19 staff and resident precautionary measures were also discussed and resources materials were emailed following today's tele-visit. **

Pre-Licensing is incomplete with the following deficiencies to be resolved by 8/14/2020. A follow up will be generated upon resolution of deficiencies.

Proof of purchasing guard grate for indoor fire pit
Fire-extinguisher inspection

LPA Leitzell is to notify the analyst in the application unit of inspection being completed and follow-up documentation needed.

An exit interview was conducted with Jolene Su, Applicant during today's tele-visit, and a copy of this report will be provided to the facility via email (sent 8/12/2020 at approximately 5:30 PM.) Two copies will be sent to the facility, 1 is to be signed and returned following day (8/13/2020) to CCL, and the other copy is to remain at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020

LIC809 (FAS) - (06/04)

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