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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001571
Report Date: 10/14/2021
Date Signed: 10/14/2021 02:24:41 PM

Document Has Been Signed on 10/14/2021 02:24 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:RICHBOROUGH FOUNTAIN, INC.FACILITY NUMBER:
347001571
ADMINISTRATOR:SALVADOR, RYANFACILITY TYPE:
735
ADDRESS:9038 RICHBOROUGH WAYTELEPHONE:
(916) 685-1194
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Josephine ShobhnaTIME COMPLETED:
02:30 PM
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 Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio explained the purpose of the visit, was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility, and confirmed no residents or staff have experienced any signs or symptoms of COVID-19 in the last 10 days. .
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility has a LIC 808 mitigation plan uploaded into FAS. LPA observed the facility to have COVID-19 informational signs, social distancing signs, hand washing signs posted throughout the facility. LPA observed a 30-day supply of PPE. The facility is able to designated and dedicated a Covid-19 bedroom, bathroom, and isolation area if needed.
 
LPA observed the temperature inside the facility was measured at 76*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 110.1 in the resident bathroom, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher is up to date with last check on 05/28/2021.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610 Emergency Disaster Plan, and Current Administrator Certificate.
 
Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with Licensee Josephine Shobhna.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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