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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004083
Report Date: 01/24/2022
Date Signed: 01/24/2022 03:09:21 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: 6DATE:
01/24/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Zanaida Berry, caregiver and
Cecilia Suaybaguio, Administrator 		TIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Zanaida Berry, caregiver, who contacted Administrator, Cecilia Suaybaguio, Administrator, who, arrived at 2:45 pm to the facility. LPA explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Facility currently has (6)residents and (1) resident is on hospice. LPA observed (6) residents to be in their private rooms napping. LPA observed (1) visitor to be leaving the facility after visiting with the resident on hospice. LPA also observed a second caregiver, Lydia Suaybaguio, to be on site.

LPA and caregiver toured the 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 and caregiver completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 72* F. LPA observed sufficient 2+day perishable and 7+day non-perishable food and PPE supply. LPA observed paper towels, soap and sanitizer and a trash can with a lid in the bathrooms. LPA observed Covid-19 posters to be posted at the front entrance and throughout facility. LPA to provide additional posters and recommended "Mask required" poster be placed outside entrance. LPA and Administrator discussed vaccination status of residents and staff and reviewed PIN 22-04, issued 1/18/2022, regarding visitation protocols. All staff are cleared and associated/requested to be associated to the facility.

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: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
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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