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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003723
Report Date: 03/28/2022
Date Signed: 03/28/2022 02:05:24 PM

Document Has Been Signed on 03/28/2022 02:05 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:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Charibel Jose, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 3/28/2022 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, 1 staff bedroom, common areas, food supply, activity room, garage, medication closet, and outdoor area. LPA and Administrator completed the infection control domain.

During inspection, LPA observed cupboard containing knives was unlocked and accessible to residents in care.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 80087(g) regarding accessible knives. Deficiency is listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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Document Has Been Signed on 03/28/2022 02:05 PM - It Cannot Be Edited


Created By: Michael Hood On 03/28/2022 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHARIBEL JOSE CARE HOME, INC.
FACILITY NUMBER: 347003723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during visit, the facility did not ensure that knives were locked and inaccessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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Facility will arrange a drawer used to lock knives and submit pictures showing corrections to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022


LIC809 (FAS) - (06/04)
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