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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002881
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:11:33 PM


Document Has Been Signed on 07/22/2022 04:11 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:CARE HORIZONS ASSISTED LIVING, LLCFACILITY NUMBER:
345002881
ADMINISTRATOR:IORDACHE-STIR, ADRIANAFACILITY TYPE:
740
ADDRESS:6630 CARE LANETELEPHONE:
(916) 205-2273
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
07/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Adriana StirTIME COMPLETED:
04:25 PM
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On 7/22/2022, Licensing Program Analyst (LPA) Cassie Yang arrived announced at the facility to conduct a Pre-licensing inspection for change of ownership referencing the infection control domain. LPA met with Administrator/Licensee, Adriana Stir, and explained the purpose of the visit. Prior to initiating the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, and front yard. In the areas toured, no immediate health, safety, or personal rights violations were observed. LPA observed sharps and toxics to be secured. Fire extinguisher was last serviced 6/13/2022. LPA advised Administrator to have all trash cans with a lid per COVID-19 precaution.

LPA and Administrator completed the infection control recommendations and facility was found to be in substantial compliance at this time. LPA confirmed that masks were worn by staff.

Component III waived as the current facility Administrator, Adriana Stir, will remain the same.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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