342700902-3-5-2021-27-AS-KLEL-BYTN69-20210305091047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700902
Report Date: 03/04/2021
Date Signed: 03/05/2021 09:11:57 AM

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:	FOLSOM COUNTRYHOUSE		FACILITY NUMBER:	342700902
ADMINISTRATOR:	LOPEZ, JANELLE		FACILITY TYPE:	740
ADDRESS:	2005 IRON POINT RD		TELEPHONE:	9168368022
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	60	CENSUS: 0	DATE:	03/04/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Janelle Lopez (Admin)		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Konnor Leitzell conducted a prelicensing visit for Folsom Countryhouse (342700902) with Janelle Lopez (Admin). Today’s prelicensing visit was done virtually due to COVID-19 precautionary measures. Today’s visit began at 10:00a.m. and was concluded at 12:00p.m. During today’s visit, the following was identified as deficient and will need to be corrected prior to licensure:

Freezer in kitchen must be maintained at a temperature of 0 degrees F
Refrigerator in kitchen must be maintained at a maximum temperature of 40 degrees F
Screening for visitors and staff at the front entrance of facility. Including a temperature check and questions regarding COVID-19.

The above corrections were made prior to completion of Prelicensing Report. All deficiencies viewed at facility have been corrected. Proof of corrections provided to LPA via photo proof.

During the Visit, LPA toured and viewed the following

Front of building. No deficiencies noted.
Side gate is locked by keypad. Indicated fire has master key for side gate. Admin indicated chime is associated with side gate notifying facility when gate is opened.
Front entrance where receptionists will be located, screening individuals prior to continuing into the facility.
Sales office where all necessary postings were viewed. Admin stated all postings will be displayed prior to residents being admitted.

Cont. LIC 809C

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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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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: FOLSOM COUNTRYHOUSE	FACILITY NUMBER: 342700902
	VISIT DATE: 03/04/2021

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Staff breakroom where chairs; a sink with soap and paper towel dispenser; lockers; and a refrigerator are available for use by Staff.
Community Directors Office: behind a locked door where sensitive information will be kept. Staff binders were viewed. All necessary documents were seen in the sample packet provided during prelicensing packet.
Both kitchens; one on first floor and the second being on the second floor. Both are identical layouts, with service kitchen attached. Kitchen is an industrial kitchen, with a 14 day supply and non-perishable foods. Refrigerator and freezer where not on at the time of visit, but LPA was informed once both get to operating temperature, photo proof will be provided to LPA for approval. Kitchen is closed off by locked doors all around.
LPA viewed both dining rooms, which were adjacent to the service kitchen. LPA noted plenty of seats provided, utensils and plates and bowls.
Hallways on both floors have lights that are motion detected, allowing for a nightlight for residents. Water fountains were viewed, but assured after photo’s are taken for facilities website, water fountains will be made inaccessible to residents during COVID-19 pandemic. Smoke and Carbon Monoxide detectors were viewed in hallways, fire extinguishes, and room numbers indicating what rooms they are. In addition to room numbers, each room has their own shadow box outside of their rooms.
Both medication rooms were viewed. Each were a locked room, with resident documents, medications in both the refrigerator and medication cart. First aid kit with all necessary requirements. Admin indicated medications will be tracked through Premier Pharmacy, and will be using Unit Dose Packaging per Agemark requirements.
2 of 2 salons: first floor holding a massage table; pedicure chair; and manicure supplies.
Wellness Room outside of room 115; under lock and key as sensitive information will be kept there.
2 of 2 washrooms: a total of 7 washers and 7 dryers. Rooms are under keypad lock, and hold cleaning detergents and linens for residents.
LPA viewed 5 of 40 rooms. Two rooms being staged with the following present: beds, closet space, chest of drawers, stools, chairs, and a lockable cabinet for personal hygiene items. When viewing private restrooms: hand bars, soap, emergency pull cord, nonskid flooring for shower were seen. In shared bathrooms, paper towels are used; in individual or couple rooms, cloth towel is being used. Hot water was viewed between 105.1 – 105.5. Admin stated water heaters will be increased to no higher than 120.

Three styles of rooms: a one person room, a companion room with a 5’ separating wall, and a couples room.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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: FOLSOM COUNTRYHOUSE	FACILITY NUMBER: 342700902
	VISIT DATE: 03/04/2021

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Stairwells were viewed, admin indicating emergency chairs will be placed in each stairwell. Proof of purchase as verification.
Innovation room on second floor for activities.
Guess bathrooms in hallways having toilet paper, grab bars, paper towels, and emergency pull cord.
Outdoor patio: chairs, shading, grassy area, garbage bins, plenty of room for activities. Down the middle of outside patio is a running water feature, water is not more than three inches deep at any point.

LPA concluded prelicensing inspection with Janelle Lopez (Admin) and completed the Component Three powerpoint with admin. LPA indicated that due to all previously identified deficiencies have been corrected, LPA is approving the prelicensing inspection.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC809 (FAS) - (06/04)

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