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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004228
Report Date: 07/21/2021
Date Signed: 07/21/2021 01:49:27 PM

Document Has Been Signed on 07/21/2021 01:49 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:FOUR SEASONS CARE HOMEFACILITY NUMBER:
347004228
ADMINISTRATOR:IOAN NAGYFACILITY TYPE:
740
ADDRESS:8322 CENTRAL AVENUETELEPHONE:
(916) 910-9419
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 3DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ioan "Johnny" Nagy, administratorTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/21/2021 to conduct a Required - 1 Year Inspection utilizing the infection control domain. Prior to initiating the annual inspection LPA completed required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA also contacted administrator and completed a facility risk assessment prior to inspection.

LPA applied hand sanitizer prior to entering the facility and wore the following personal protective equipment (PPE) during today's visit: surgical mask. LPA met with administrator Johnny Nagy and explained the purpose of the visit.

LPA and administrator toured the home together, areas toured include but are not limited to: common areas, kitchen, resident bedrooms, bathrooms, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at facility.

Administrator to send Community Care Licensing (CCL) updated copies of LIC 500 - Personnel Report, LIC 808 - Mitigation Plan, and LIC 308 - Designation of Facility Responsibility by 07/28/2021.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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