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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002721
Report Date: 04/12/2022
Date Signed: 04/12/2022 12:07:08 PM


Document Has Been Signed on 04/12/2022 12:07 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ADINA HOME CAREFACILITY NUMBER:
347002721
ADMINISTRATOR:LUP, ILEANAFACILITY TYPE:
740
ADDRESS:260 BAURER CIRCLETELEPHONE:
(916) 817-2471
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 0DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Ileana LupTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Lavinia Muscan and Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with administrator Ileana Lup during today's 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

LPA toured the facility with administrator. Currently there are no residents living in the facility. Currently administrator and family lives in the home. Administrator understands to contact CCL if she decides to admit residents.

Facility agrees to submit an LIC 610E new disaster plan, liability insurance, an updated LIC 500, and a mitigation plan.

.Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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