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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000885
Report Date: 08/04/2021
Date Signed: 08/04/2021 02:48:50 PM

Document Has Been Signed on 08/04/2021 02:48 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BARRIENTOS CARE HOMEFACILITY NUMBER:
347000885
ADMINISTRATOR:BARRIENTOS, CECILFACILITY TYPE:
735
ADDRESS:6900 13TH STREETTELEPHONE:
(916) 427-1951
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 5DATE:
08/04/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Co-Licensee Yvonne Barrientos, and Administrator Hidemy La Bryer.TIME COMPLETED:
01:00 PM
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THIS REPORT IS AMENDED TO CORRECT THAT THE MEETING WAS HELD ON MICROSOFT TEAMS NOT WEBEX.
An Office visit was conducted today in the Sacramento South Regional Office via Webex Video. The purpose of this meeting is to discuss the well-being of the Licensee and residents, and to remain in substantial compliance with the regulations. Present in the meeting is Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Victoria Brown, Co-Licensee Yvonne Barrientos, and Administrator Hidemy La Bryer.
Issues discussed during the meeting were:
· Facility staff/client update
· Licensee/Administrator/Designee accountability/Administrator duties/Process
· Coverage at facility in case of absence of Administrator/Registry
· Plan for staffing in cases of covid/Fit testing for all staff
· Facility Roster
· Mitigation Plan
· Any changes to facility CCL is to be notified
The licensee agrees to do the following:
-Submit SIR for resident hospitalization of 8/2/21
-Submit confirmation that all staff has been fit testing for N95 masks per CalOsha law
-Contact Registry/HCO for staffing coverage contract prior to emergencies/ensure all staff are fingerprint cleared and associated to the facility
-Facility Roster to be updated
-Submit a Personnel Report (LIC500) to include hours and work schedules for all staff
-Designation of Administrative Responsibility (LIC308)
-Contact LPA Victoria Brown to review changes needed for Mitigation Plan
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited during this visit. An exit interview was conducted with Co-Licensee Yvonne Barrientos, and Administrator Hidemy La Bryer via Microsoft Teams and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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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