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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002857
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:15:45 PM


Document Has Been Signed on 10/07/2022 03:15 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:ROBERT CREEK VILLAFACILITY NUMBER:
345002857
ADMINISTRATOR:KING, MARICARFACILITY TYPE:
740
ADDRESS:8134 ROBERT CREEK COURTTELEPHONE:
(925) 597-8181
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
10/07/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Mari King, Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unanounced to conduct a post-licensing inspection. LPA met with Maricar King, Administrator, and explained purpose of inspection. Robert King, Licensee, arrived at 2:00 pm. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. There are (6) clients who reside at the home. LPA observed (6) clients in the facility to be napping and was advised (0) clients are on hospice.

LPA and Administrator/Licensee toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2.5) resident bathrooms, kitchen, laundry area, staff room and outside storage. LPA observed the home to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 72* F. Fire extinguisher last serviced 7/15/2022. Facility conducts quarterly fire drills and the smoke/monoxide alarms are in working order. The facility has a back yard area with covered seating and there is (1) unlocked exit gate. Each exit door has an alarm as well as the outside gate. Residents use a necklace pendant that sounds in the kitchen. LPA observed toxins, sharps and medications to be locked in a separate areas. LPA observed sufficient 2+day perishable/7+day non-perishable food and sufficient PPE on hand. LPA observed paper towels, soap, sanitizer- will place trash cans with lids in each bathroom. Discussed resident and staff vaccination status and eligibility for booster shot. LPA provided booster flyer. LPA observed various Covid posters and required postings throughout. All staff are cleared and associated. LPA observed current Administrator certificate # 6059215740-exp 6/29/2023.

LPA requested copy a current copy of liability insurance be provided by 10/14/2022.

There were no deficiencies observed. Exit interview. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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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