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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001667
Report Date: 07/21/2021
Date Signed: 07/21/2021 01:53:32 PM

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:LUCIAN'S HOMEFACILITY NUMBER:
347001667
ADMINISTRATOR:MITITI, VASILE LUCIANFACILITY TYPE:
740
ADDRESS:8254 MOSS OAK AVENUETELEPHONE:
(916) 879-0879
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dan Mititi (Admin)TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 7/21/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Dan Mititi (admin) and explained the purpose of the visit. Prior to initiating the annual inspection, 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff and answers were documented in their visitor screening log.

LPA and admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) of five (5) resident bedrooms, one (1) of one (1) staff bedroom, three (3) bathrooms, office, kitchen, dining room, garage, laundry area and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time. Facility is to supply LPA with the following documents via email to Konnor.Leitzell@dss.ca.gov by COB 7/30/2021: Designation of Administrative Responsibility (LIC 309) and Personnel Report (LIC 500); current administrator certificate; Proof of Limited Liability Insurance; Neighborhood Complaint Procedures.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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