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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700867
Report Date: 04/14/2022
Date Signed: 04/14/2022 05:29:19 PM


Document Has Been Signed on 04/14/2022 05:29 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ALC ASSISTED LIVING INC.FACILITY NUMBER:
342700867
ADMINISTRATOR:LITA, JOHN D.FACILITY TYPE:
740
ADDRESS:6705 JUDISTINE DRIVETELEPHONE:
(916) 844-7052
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Jeanina Lup, Co-Administrator TIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced on 4/14/2022 to conduct a case management inspection for overdue annual fees. LPA met with, Jeanina Lup, Co-Administrator, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN-95 Mask.

LPA discussed reason for inspection with Jeanina Lup, Co-Administrator, who stated that she believed annual fees were paid when they were due (9/1/2021). LPA confirmed in the Department's system that the annual fees were paid on/around 9/16/2021, so a 50% late fee was assessed.

LPA provided balance and PIN information to Co-Administrator who paid current balance in full during today's inspection. LPA observed confirmation of payment in full during inspection.

LPA observed (2) residents to be eating dinner in the kitchen and (2) residents to be in their room. In areas toured, LPA did not observe any health and/or safety risk to residents.

There are no deficiencies being cited today.

Exit interview. Copy of report provided to Administrator.





SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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