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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004232
Report Date: 04/21/2022
Date Signed: 04/21/2022 01:45:33 PM


Document Has Been Signed on 04/21/2022 01:45 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:ORANGEVALE HOME CAREFACILITY NUMBER:
347004232
ADMINISTRATOR:SMILCA CAZAFACILITY TYPE:
740
ADDRESS:6829 BEECH AVENUETELEPHONE:
(916) 987-8878
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 0DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Caza Smilca, LicenseeTIME COMPLETED:
02:15 PM
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On April 21, 2022, On April 21, 2022, Licensing Program Analyst DeAnna Williams-Lyons arrived unannounced to conduct a required 1 Year Annual Inspection. LPA met with Caza Smilca, Licensee, and informed her the reason for the visit. Prior to the 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

LPA and Caza completed the Infectious Control questionnaire with no issues to report.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. Fire drills are conducted as required. LPA observed an adequate amount of linens and found the first aid kit to be complete.

To continue see 809 C...

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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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: ORANGEVALE HOME CARE
FACILITY NUMBER: 347004232
VISIT DATE: 04/21/2022
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LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

Medications were not checked due to not having any residents. No staff files were checked due to not having any staff at this time.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than May 21, 2022.

Per California Code of Regulation Title 22, no citations were issued today.

An exit interview was conducted and a copy of this report was given to Caza.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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