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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004083
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:50:54 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:A & C CARE HOMEFACILITY NUMBER:
347004083
ADMINISTRATOR:SUAYBAGUIO, CECILIAFACILITY TYPE:
740
ADDRESS:2949 GARFIELD AVETELEPHONE:
(916) 488-8114
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Cecilia Suaybaguio, Administrator TIME COMPLETED:
01:55 PM
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Licensing Program Analysts (LPA) Sabrina Calzada and Michael Hood arrived unannounced to conduct a required annual inspection. LPA's met with Cecilia Suaybaguio, Administrator and explained purpose of inspection. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA's were screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: double surgical mask and N95 mask There are (5) residents at the facility and no residents are currently receiving hospice services. LPA's observed (2) staff also present, wearing masks.

LPA observed (1) resident to be visiting in the dining room with a visitor. LPA's observed that (4) residents were napping or in their rooms during the inspection. LPA's and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (6) resident bedrooms, (2) resident restrooms, kitchen, dining room, and laundry area. LPA's and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 72* F. Alarm door motion sensors were tested and also work throughout facility. LPA observed 2+day perishable and 7+day non-perishable food supply. LPA's observed Covid posters near the kitchen -Administrator posted a few more during the inspection. PPE supply observed and is sufficient for 30+ days. Fire extinguisher last serviced 11/2/2020.

Resident and staffing vaccinations discussed as well as current requirements for weekly testing. LPA's requested updated copies of LIC610E, LIC500 and insurance policy- to be faxed to the DSS by 9/4/2021.

There were no deficiencies cited as a result of todays inspection.

Exit interview conducted with Administrator, and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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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