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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004151
Report Date: 12/08/2023
Date Signed: 12/08/2023 04:53:35 PM

Document Has Been Signed on 12/08/2023 04:53 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SEGOVIA'S CARE HOME #3FACILITY NUMBER:
347004151
ADMINISTRATOR:SEGOVIA, NIMFA C.FACILITY TYPE:
735
ADDRESS:6412 SYLVAN ROADTELEPHONE:
(916) 223-5315
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 5DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nimfa Segovia, Administrator TIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Erika Follosco, DSP and Jecca Keifert, DSP. Chanel Segovia, DSP, and Nimfa Segovia, Administrator, arrived shortly. LPA explained purpose of inspection. The facility is an Adult Residential Facility (level 4F) that is vendorized through Alta California Regional Center. LPA observed (2) clients present at the start of the inspection and (3) clients return from day program during the inspection.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) client bedrooms, (2) bathrooms, kitchen, laundry area and backyard. LPA observed the home to be clean, safe and in good repair. LPA observed various Covid posters throughout as well as other required postings, including House Rules and personal rights. Personal Rights to be updated to include (18). LPA observed locked sharps in the kitchen, medications secured nearby and locked toxins in the laundry area. LPA observed sufficient 2+day perishable, including fresh produce, and 7+day non-perishable food. Hot water measured 106*F in the kitchen. There is sufficient linen/blankets/paper supplies/PPE on hand. Inside temperature measured 68* F. First aid kit is complete. Fire extinguisher last serviced 1/24/23 and smoke/monoxide alarms are in working order. LPA observed monthly documentation of fire drills and Resident Council meetings. The facility has a large back yard area with seating and various gardens. There are no pools/ponds. Only non-ambulatory resident resides in room #1, per fire clearance. All clients have their own room key and staff have an extra set. Administrator certificates are current- ARF #602199735 exp 1/13/24; RCFE #601 2199740- exp 1/29/25. Land line phone obtained. LPA reviewed (7) staff files- all paperwork is current, staff are cleared/associated and have current First Aid/CPR and other required training. (2) resident files were reviewed and found to be organized and current with documentation. Medications were reviewed for the same (2) residents- orders matched medications being administered and documentation is current. P&I funds were reviewed for (2) residents- records match funds on hand. Infection Control Plan was reviewed and approved. Emergency Disaster Plan is current.
There are no deficiencies issued. Exit interview. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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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