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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002866
Report Date: 03/01/2022
Date Signed: 03/01/2022 03:10:47 PM


Document Has Been Signed on 03/01/2022 03:10 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 VILLA IIFACILITY NUMBER:
345002866
ADMINISTRATOR:KING, MARICARFACILITY TYPE:
740
ADDRESS:8138 ROBERT CREEK COURTTELEPHONE:
(925) 567-8181
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
03/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maricar King, AdministratorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with licensee/administrator Maricar King 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. In addition, staff screened LPA upon entrance.
Facility was inspected both indoors and outdoors. LPA inspected 5 resident bedrooms, 1 staff room, 5 bathrooms, common living areas, and kitchen. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. Centrally stored medications will be locked in the kitchen cabinets. The facility has adequate lighting throughout and night lights in the hallways. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. LPA observed grab bars and non-skid mats present in the bathrooms. Smoke detectors and carbon monoxide detectors were checked and operational. Fire clearance was granted on 11/24/21 for 6 non-ambulatory residents. Staff room is off the kitchen area in the back room. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for resident use.

Competent III was completed on 2/15/2022 with licensee. This report will be forwarded to the centralized application unit for continued processing.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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