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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002978
Report Date: 11/15/2022
Date Signed: 11/15/2022 01:47:48 PM


Document Has Been Signed on 11/15/2022 01:47 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:PINNACLE HOME CARE 2FACILITY NUMBER:
345002978
ADMINISTRATOR:DAVTYAN, LUSINEFACILITY TYPE:
740
ADDRESS:4500 HUMMINGBIRD CIRCLETELEPHONE:
(916) 771-9420
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 0DATE:
11/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Applicant, Lusine DavtyanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Lavinia Muscan met with Applicant, Lusine Davtyan, to conduct an announced Pre- Licensing visit. LPA followed current Covid precautions- self screened, hand sanitized and surgical mask worn. Facility Administrator will be Lusine Davtyan. Administrator holds a current administrator certificate (# 6054365740 with expiration date 12/3/2023).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. Facility inspection is done for these areas but not limited to three (3) bedrooms , three (3) bathrooms, storage area, outside area and laundry area . Bathrooms and bedrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguisher is ready for emergency use. Facility was approved for 4 non-ambulatory and 2 bedridden residents. Water temperature read at 114*.

Component III for RCFE was waived with Licensee during today's visit because Licensee is relocating. LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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