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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001629
Report Date: 04/28/2022
Date Signed: 04/28/2022 04:24:42 PM

Document Has Been Signed on 04/28/2022 04:24 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, 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: 5DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Andrei Costea, Administrator/LicenseeTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 4/28/2022 to conduct a complaint visit. LPA met with S1, Administrator's son. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. In addition, LPA was screened for symptoms at entrance.

On 11/21/2022, Community Care Licensing Division Inspection Branch (CCLDIB) Investigator Joseph Balarie was present at the facility and observed an uncleared adult (S1) working at the facility. Investigator Balarie learned that during the pandemic, S1 had taken a full-time roll at Maria's Home Care working Monday thru Friday from 0630 hours to 1800 hours. LPA Williams looked up S1's status in Guardian and found that he is Not Eligible to work, with a determination status of "Closed - Determination Closed".

At the time of LPA's visit today (04/28/2022), S1 was the only staff member working. S1 immediately called Administrator/Licensee to arrive.

Deficiencies cited on LIC 809-D.

Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 04:24 PM - It Cannot Be Edited


Created By: Jacob Williams On 04/28/2022 at 10:38 AM
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2022
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(e) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or.
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Administrator agrees to have caregiver fingerprint cleared and associated to the facility. Adminsitrator is to send into CCL their plan of ensuring all staff to be associated and fingerprint cleared.
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This requirement is not met as evidenced by: Based on observation, records review, and interviews, Adminsitrator did not have staff (S1) fingerprint cleared.
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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: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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