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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004083
Report Date: 01/19/2023
Date Signed: 01/19/2023 12:10:06 PM


Document Has Been Signed on 01/19/2023 12:10 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: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:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:CaregiverTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/19/23 to conduct a Annual Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed the Department's required COVID-19 protocols, LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

Administrator arrived at the facility. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA discussed and advised regarding: Use of Guardian to ensure all staff are associated, PRN authorization and documentation as needed, care plans up to date and address restricted health conditions as needed, gates repaired to operate well after storms, report catastrophic events such as power outages, maintain records of emergency drills and review and update emergency plan as needed at least annually.


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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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