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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700902
Report Date: 03/29/2022
Date Signed: 03/29/2022 02:45:43 PM


Document Has Been Signed on 03/29/2022 02:45 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:FOLSOM COUNTRYHOUSEFACILITY NUMBER:
342700902
ADMINISTRATOR:LETICIA HIGARESFACILITY TYPE:
740
ADDRESS:2005 IRON POINT RDTELEPHONE:
(916) 836-8022
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:60CENSUS: 21DATE:
03/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Mustafa Ali-Mahgoub, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPAs) Bethany Mirlohi and Lavinia Muscan arrived unannounced to conduct a POC visit. LPA met with Administrator , during today's 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

LPA's toured the facility with administrator and observed 4 resident rooms and bathrooms. LPA's observed all 4 resident rooms and bathrooms to be clean and sanitary. LPA cleared deficiency during today's inspection.

Administrator to send into LPA a copy of the plan on how they will keep resident bathrooms in a clean and sanitary condition by 3/31/22.

In addition, LPA's received LIC308 and administrator certificate of the new administrator.

Exit interview conducted and copy of report and letter of clearance was provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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