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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700902
Report Date: 02/10/2023
Date Signed: 02/10/2023 10:50:39 AM


Document Has Been Signed on 02/10/2023 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:FOLSOM COUNTRYHOUSEFACILITY NUMBER:
342700902
ADMINISTRATOR:THACH DUONGFACILITY TYPE:
740
ADDRESS:2005 IRON POINT RDTELEPHONE:
(916) 836-8022
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:60CENSUS: 35DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director: Thach Jimmy Duong TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 02/10/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director (ED), Thach Jimmy Duong, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, six (6) bathrooms, kitchen, and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time. PPE supplies is adequate. LPA went over PIN 23-02-ASC - UPDATED GUIDANCE ON TESTING, ISOLATION AND QUARANTINE with ED.

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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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