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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003247
Report Date: 12/14/2021
Date Signed: 12/14/2021 10:29:06 AM

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:EMILY'S GUEST HOMEFACILITY NUMBER:
347003247
ADMINISTRATOR:TINTAS, MARIAFACILITY TYPE:
740
ADDRESS:7437 KANAI AVENUETELEPHONE:
(916) 745-3711
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 2DATE:
12/14/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria Tintas TIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 12/14/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Licensee, Maria Tintas, 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 and 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: Surgical Mask. Additionally, LPA were screened by Licensee upon entering the facility.

LPA toured the interior and exterior of the facility together with Licensee to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, one (1) bathroom, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA requested for documents from Licensee while at the facility and received copies of Administrator Certificate and LIC 308 Designation of Facility Responsibility. LPA also requested for Liability Insurance. Licensee will email a copy of Liability Insurance to LPA.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report sent to Licensee via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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