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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002951
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:50:13 PM

Document Has Been Signed on 02/07/2023 02:50 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:LIVING WATER CARE HOME INC, THEFACILITY NUMBER:
345002951
ADMINISTRATOR:PRANOTO, HERLINAFACILITY TYPE:
740
ADDRESS:7800 CLAYPOOL WAYTELEPHONE:
(279) 529-2233
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 4DATE:
02/07/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Herlina Pranoto, Administrator TIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a post-licensing inspection. LPA met with Herlina Pranoto, Administrator, and explained purpose of inspection. Also present was staff, Yeni Sulistioani Oey. Prior to initiating today's inspection, LPA completed required COVID-19 department protocols, was screened per Covid-19 precautionary measures upon entering the facility, and wore a:surgical mask. There are (4) clients currently and (0) clients receiving hospice services. LPA observed (1) client to be in the common area and (3) clients to be in their room at the start of the inspection.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (4.5) bathrooms, kitchen, laundry/storage area, and (1) staff room. LPA observed the home to be clean, safe,and in good repair. All resident rooms had the required furniture. LPA observed locked sharps in the kitchen, locked medications in a cabinet nearby and locked toxins in the laundry/garage area. LPA observed sufficient 2+day perishable/7+day non-perishable supply of food and sufficient paper products and PPE on hand. LPA observed paper towels, soap, sanitizer, trash cans with lids and 20-second hand-washing poster in each bathroom. Inside temperature was observed to be 68* F. Fire extinguisher last serviced 3/14/22- aware its needs to be serviced by 3/14/23. The facility has a back yard area with covered seating and (1) unlocked exit gate. LPA observed various Covid posters throughout and at the front door. LPA recommended posting a "Mask Required" poster outside the front entrance. All staff are cleared and associated. LPA observed current Administrator certificate #6063770740- exp 11/13/24. Administrator provided an electronic copy of Mitigation Plan and will print a copy also. LPA reviewed (2) resident binders and found the required forms to be on file. Administrator to ensure updated medical assessments are obtained timely. LPA reviewed (1) staff file and found it to contain the required forms and current First Aid/CPR certification. Discussed resident and staff vaccination status. LPA provided a vaccination flyer. LPA to email blank LIC9282- Infection Control Plan. Administrator to provide a current copy of liability insurance- by email 2/12/23.
There were no deficiencies observed. Exit interview. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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