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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003327
Report Date: 10/27/2021
Date Signed: 10/27/2021 11:57:03 AM

Document Has Been Signed on 10/27/2021 11:57 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:AILEEN CANTOR-FERMO RESIDENTIAL CARE HOMEFACILITY NUMBER:
347003327
ADMINISTRATOR:FERMO-CANTOR, AILEENFACILITY TYPE:
735
ADDRESS:7016 22ND STREETTELEPHONE:
(916) 992-1904
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 4DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Aileen Cantor, LicenseeTIME COMPLETED:
12:15 PM
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On October 27 2021, at 10:45am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with Aileen Cantor, Executive Director and explained purpose of inspection. Prior to initiating the 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 completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by the administrator upon arrival.

Aileen and LPA completed the inspection tool questionnaire with no issues or advisories to report.

LPA observed the following: Administrators Certificate is valid. First Aid Kit was complete and ready for emergency use. Fire extinguishers fully charged. Smoke detector and Carbon Monoxide detector are functional. Facilities temperature measured 74 degrees F.
Common areas were clean and in good repair. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away. LPA reviewed 2 resident files and 2 Staff files.

To continue see 809-C...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AILEEN CANTOR-FERMO RESIDENTIAL CARE HOME
FACILITY NUMBER: 347003327
VISIT DATE: 10/27/2021
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Resident files have all the required documentation and signatures. Staff files shows Criminal Record Clearances, First Aid Certificates, and staff training is being conducted as required.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than November 27, 2021.

Exit interview conducted and a copy of this report given to Aileen Cantor

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: AILEEN CANTOR-FERMO RESIDENTIAL CARE HOME
FACILITY NUMBER: 347003327
VISIT DATE: 10/27/2021
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Resident files had all the required documentation and signatures. Staff files showed Criminal Record clearances, First aid Certificates and staff training is being conducted as required.

As a result of this inspection, no citations are being issued.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than November 27, 2021.

.An exit interview was conducted and a copy of this report was given to Aileen Cantor.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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