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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002857
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:38:55 PM


Document Has Been Signed on 02/03/2023 02:38 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:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rodel Besana and Prescy Precila, staff TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met Rodel Besana and Prescy Precila, staff. LPA was advised that Maricar KIng, Administrator, was not at the facility today. LPA explained purpose of inspection. LPA observed (1) resident in the common area and (5) residents in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently, there are (0) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility.

LPA and caregiver/Administrator Designee, toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (3) resident bathrooms, kitchen, staff room and laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen and locked medications nearby. LPA observed the inside temperature to be 73*F. The fire extinguisher was last serviced on 7/13/22. Discussed vaccination status of residents/staff and eligibility for boosters. LPA observed multiple Covid posters throughout as well as other required postings including the Infection Control Plan and Mitigation Plan. LPA reviewed Infection Control Plan (20 pages) and found it to be comprehensive. LPA observed (1) unlocked gate from the inside back patio and outdoor seating with shade. LPA observed sufficient incontinent, paper and PPE products on hand. Discussed PIN 22-28.1 issued 11/29/22 regarding current visitor protocols. A "mask required " sign to be posted outside the front door. LPA reviewed (1) resident binder and found it to be complete and contain current documentation.

LPA requested an updated copy of the LIC308 and LIC500 be sent by 2/10/23. A copy of current liability insurance was recently provided.

There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
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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