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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002633
Report Date: 07/20/2022
Date Signed: 07/20/2022 10:26:28 AM


Document Has Been Signed on 07/20/2022 10:26 AM - 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: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:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emilia PetcuTIME COMPLETED:
10:30 AM
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On 7/20/2022 Licensing Program Analyst (LPA) Lavinia Muscan, arrived at the facility unannounced to conduct an annual visit using the infection control tool visit. LPA met with Facility Administrator, Emilia Petcu and explained the purpose of the visit. Prior to initiating the visit, 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 she used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Administrator.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, outside area and common restrooms. Facility has a 2 day perishable and a 7 day non-perishable amount of food. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

Administrator agrees to send in LIC500 and liability insurance.

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: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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