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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001629
Report Date: 08/13/2021
Date Signed: 08/13/2021 05:37:30 PM

Document Has Been Signed on 08/13/2021 05:37 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:MARIA'S HOME CAREFACILITY NUMBER:
347001629
ADMINISTRATOR:ANDREI COSTEAFACILITY TYPE:
740
ADDRESS:5914 CANARY DRIVETELEPHONE:
(916) 344-5487
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 2DATE:
08/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Andrei CosteaTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacob Williams conduced a Case Management health and safety check with Administrator Andrei Costea and care staff Jadeene Johnson, in relation to the department receiving a priority 1 complaint. Prior to visit, LPA conducted self-assessment and had no COVID-19 related symptoms. During visit, LPA was wearing an N95 respirator for COVID-19 precautionary measures.

During the health and safety check, LPA toured the facility including but not limited to the kitchen, living room, family room, dining room, pantry, and bathroom. LPA observed passageways appeared to be free of obstruction. The facility appeared to be in good repair.

While requesting a list of documents for investigation, facility was missing documents for resident and staff including but not limited to Physician's Report, Resident Roster, symptom check and sign-in sheet for visitors and staff. See LIC809-D.

Deficiencies cited during inspection. Exit interview conducted and a copy of the report provided to Administrator
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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 2
Document Has Been Signed on 08/13/2021 05:37 PM - It Cannot Be Edited


Created By: Jacob Williams On 08/13/2021 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MARIA'S HOME CARE
FACILITY NUMBER: 347001629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
CCR
87506(d)

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87506(d): All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
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Licensee shall ensure that all records pertaining to each resident are secured in the facility file and available for review upon request. A statement of understanding shall be submitted by POC due date.
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This requirement is not met by adminstrator not able to provide resident R1 files during the visit. Administrator looked at his home residence and Physicians Report. still missing. This presents an immediate health and safety risk to the resident in care.
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Type B
08/27/2021
Section Cited
CCR87468.1(a)(2)

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87468.1 Personal Rights (a)(2): To be accorded safe, healthful and comfortable accomodations, furnishings and equipment. This requirement was not met as evidence by:
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Licensee agrees to submit a self-certification letter regarding conducting COVID-19 screening of all visitors and staff and submit proof to LPA by POC Date.
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Based on observation and records review, Licensee does not follow facility COVID-19 screening protocols for visitors including sign-in sheet, screening questionnaire upon entering which poses an immediate health and safety risk to all clients in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Jacob Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


LIC809 (FAS) - (06/04)
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