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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002811
Report Date: 12/10/2021
Date Signed: 12/13/2021 01:40:24 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:BU-WON CARE HOMEFACILITY NUMBER:
347002811
ADMINISTRATOR:YANG, BU-WON K.FACILITY TYPE:
740
ADDRESS:1035 ELSWORTH WAYTELEPHONE:
(916) 467-7510
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 4DATE:
12/10/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Bu-Won YanTIME COMPLETED:
04:30 PM
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On 12/10/2021 LPA Tryon visited the facility to perform an Annual Inspection using the Infection Control Domain of the Annual Tool.

Prior to visiting, LPA had contacted the facility and did a quick screen to learn that there are no COVID positive residents or staff at this time. LPA screened prior to entering including taking temperature and using hand sanitizer.
LPA requested a copy of most recent Administrator Certificate, copy of liability insurance, and current staff schedule. LPA received copies of Insurance and staff schedule. The Administrator Certificate is forthcoming.

A Technical Advisory was issued regarding N-95 Fit Testing. The facility is in the process of finding a resource.

The facility appears to be in substantial compliance at this time.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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