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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002088
Report Date: 02/11/2022
Date Signed: 02/11/2022 03:28:13 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:DELL VILLA CARE HOMEFACILITY NUMBER:
347002088
ADMINISTRATOR:DUNCAN, GREGORYFACILITY TYPE:
740
ADDRESS:8900 FAIR OAKS BLVD.TELEPHONE:
(916) 944-8148
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 2DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Gregory DuncanTIME COMPLETED:
03:30 PM
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On 2/11/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Donnica Duncan, Caregiver, and explained purpose of inspection. LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive COVID-19 diagnoses. LPA was screened per COVID-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.The facility has an approved mitigation plan. Administrator , Gregory Duncan, arrived to the facility shortly afterwards. LPA was informed that all (2) residents are on hospice.

LPA toured the interior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathroom, kitchen, and (2) private resident rooms. In the areas toured no immediate health, safety, or personal rights violations were observed. The temperature inside the facility was observed to be 74* F. LPA observed medications, sharps and toxics to be secured. LPA observed the fire extinguisher to be last serviced in December 22, 2016. LPA advised Administrator to have trash bin with lid and paper towels in the shared restroom. LPA observed the front door bell to be disabled. LPA advised Administrator to change the door bell by the end of next week. LPA advised Administrator to have a thorough documentation of visitor sign-in including temperature check and vaccination status. LPA requested proof of an up to date fire extinguisher by 2/14/2022. LPA and Administrator completed the a review of infection control and facility was found to be in compliance at this time. LPA and Administrator discussed vaccination status of residents and staff.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: DELL VILLA CARE HOME
FACILITY NUMBER: 347002088
VISIT DATE: 02/11/2022
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Administrator reported to LPA that he is considering closing the facility in the future. Administrator explained that he is turning 68 and may retired soon. LPA informed Administrator to contact CCLD for proper protocols to be taken place. Administrator responded he understood and will be in touch regarding this matter.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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