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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004054
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:59:08 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:CALVIN DRIVE CARE HOMEFACILITY NUMBER:
347004054
ADMINISTRATOR:PUHA, MIRCEAFACILITY TYPE:
740
ADDRESS:7221 CALVIN DRTELEPHONE:
(916) 723-1374
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
12/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mircea Puha, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 12/22/2021 to conduct a Case Management visit regarding a change in the facility's fire clearance after staff bedroom was changed to a resident bedroom. LPA met with Administrator, Mircea Puha, and explained the purpose of the visit. Prior to initiating the visit, 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 and Administrator toured all 5 residents bedrooms. LPA observed all bedrooms to be clean and in good condition. LPA obtained a copy of an updated facility sketch to reflect the change of bedrooms.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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