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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003723
Report Date: 12/10/2021
Date Signed: 12/10/2021 03:44:57 PM

Document Has Been Signed on 12/10/2021 03:44 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:CHARIBEL JOSE CARE HOME, INC.FACILITY NUMBER:
347003723
ADMINISTRATOR:JOSE, CHARIBELFACILITY TYPE:
735
ADDRESS:5831 TREE HILL CTTELEPHONE:
(916) 332-5277
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 4DATE:
12/10/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Charibel Jose, AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 12/10/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Charibel Jose, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 2 bedrooms and 2 bathrooms for residents, common area, activity room, dining room, food supply, garage, laundry room, PPE supply, outdoor area, and shed. 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.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
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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