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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001971
Report Date: 07/19/2021
Date Signed: 07/19/2021 03:55:07 PM

Document Has Been Signed on 07/19/2021 03:55 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:RICK AND NICOLE FORTES CARE HOMEFACILITY NUMBER:
347001971
ADMINISTRATOR:FORTES, NICOLEFACILITY TYPE:
735
ADDRESS:5545 VILLAGE WOOD DRIVETELEPHONE:
(916) 395-3225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 5DATE:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Nicole FortesTIME COMPLETED:
04:00 PM
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On 07/19/21 at 3:15 PM, LPA Suong Teh arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by the facility administrator Nicole Fortes and staff Norma Mercado. LPA was screened upon entry for COVID precautions. LPA explained the purpose of the visit to Nicole. Staff Norma accompanied LPA on facility tour

LPA Teh inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications were noted to not be accessible to residents in care. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan and approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tuyet-Suong Teh
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: RICK AND NICOLE FORTES CARE HOME
FACILITY NUMBER: 347001971
VISIT DATE: 07/19/2021
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Water temperature reads 110 F and the facility temperature registered at 75 F. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were 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 was checked December 10, 2020. Facility has an emergency food and water supply in a separate storage area in kitchen. LPA requested the following documents to be updated: LIC 500, LIC 610E, and LIC 308.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Nicole Fortes.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tuyet-Suong Teh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC809 (FAS) - (06/04)
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