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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004228
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:56:19 PM


Document Has Been Signed on 08/04/2022 04:56 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:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Ioan NagyTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/04/22 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 asked questions from administrator and completed a facility risk assessment prior to facility entry. 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 Ioan 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,4 resident bedrooms, 2 bathrooms,2 staff rooms 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.

As a result of today's inspection, deficiency Type-B is cited pursuant to California Code of Regulations, Title 22, Section 87412(a)(13)(B)1 regarding expired administrator's certificate for current administrator.
Deficiency is listed on LIC809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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Document Has Been Signed on 08/04/2022 04:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 347004228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During annual inspection on 08/04/22, LPA found that facility administrator has expired administartor certificate- Ioan Nagy (#6019660740, 08/07/20)
POC Due Date: 09/04/2022
Plan of Correction
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 Licensee agrees to submit in the required documentation to associate an Administrator with an active/current administrator certificate to the facility to LPA by 09/04/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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