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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002866
Report Date: 01/19/2023
Date Signed: 01/19/2023 05:08:22 PM


Document Has Been Signed on 01/19/2023 05:08 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: 4DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Maricar King, Administrator TIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met Maricar KIng, Administrator. LPA observed a second caregiver, Apolinario "Nari" Macaraeg preparing dinner in the kitchen. LPA explained purpose of inspection. LPA observed (2) residents in the common area and (2) 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 Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (3) resident bathrooms, (1) guest bathroom, 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 and medications in the kitchen. LPA observed the inside temperature to be 74*F. LPA observed activities on site. The fire extinguisher was last serviced on 7/13/22. All staff are cleared and associated to the facility.
Discussed vaccination status of residents/staff and eligibility for boosters. Booster flyer was provided. Administrator to schedule an upcoming booster clinic for the newest vaccine. LPA observed multiple Covid posters throughout as well as other required postings including the Infection Control Plan and Mitigation Plan. LPA observed (1) unlocked gate from the inside back patio. There are no bodies of water or a pool. LPA observed sufficient incontinent and PPE products on hand. Discussed PIN 22-28.1 issued 11/29/22 regarding current visitor protocols. A "mask required " sign is posted outside the front door.

LPA requested an updated copy of the LIC308, LIC500 and current liability insurance be provided by 1/30/23.

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: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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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