<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002886
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:19:11 AM


Document Has Been Signed on 02/17/2022 11:19 AM - 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:CITRUS CREST CARE HOME 1FACILITY NUMBER:
345002886
ADMINISTRATOR:SOUMAHORO, MARIAM GFACILITY TYPE:
740
ADDRESS:6906 HENNING DRIVETELEPHONE:
(916) 728-1338
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 3DATE:
02/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mariam G Soumahoro, AdministratorTIME COMPLETED:
11:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains met with applicant, Mariam G Soumahoro, to conduct a Pre- Licensing visit. This application is a change in ownership. This address is currently licensed as CITRUS CREST CARE HOME Facility #: 342700559. The facility has a fire clearance for six (6) non-ambulatory residents with a hospice waiver for three (3) residents. Applicant holds a current administrator certificate (#6049437740 with expiration date 8/22/2022).

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and two (2) bathrooms for resident use, along with three (3) bedrooms and one (1) bathroom for staff. LPAs observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 107 degrees F. LPAs checked the kitchen area for the ability to prepare and store food. LPAs observed at least a 2-day perishable and 7-day nonperishable food supply at the facility. LPAs observed cleaning products and other toxins to be locked away. LPAs observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguisher is ready for emergency use. LPAs reviewed two resident files and two staff files.

LPAs observed during visit that exit door to backyard with sensor was not properly functioning and Administrator's file was incomplete. LPAs indicated all the above observations need to be fixed and facility will send corrections to CCLD within 7 days from today's date.

Pre-licensing passed and Component III waived. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1