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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002633
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:17:15 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:PINE GROVE RESIDENTIAL HOME CARE FOR THE ELDERLYFACILITY NUMBER:
347002633
ADMINISTRATOR:CATUNA. REGHINAFACILITY TYPE:
740
ADDRESS:7213 PINE GROVE WAYTELEPHONE:
(916) 987-1655
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 6DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Emilia Petcu (Designated Admin)TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 06/28/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Emilia Petcu (Designated Administrator/Caregiver) 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 Emilia and responses were documented in the visitor screening log.

LPA and Emilia toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, dining room, five (5) of five (5) resident bedrooms, two (2) resident (2) bathrooms, one (1) of one (1) staff bathroom, staff room, kitchen, storage, garage and backyard. LPA conducted interviews with three (3) of six (6) residents in care. 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.

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: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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