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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004314
Report Date: 11/10/2021
Date Signed: 11/10/2021 01:59:02 PM

Document Has Been Signed on 11/10/2021 01:59 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JO BIGORNIA HOME WILTONFACILITY NUMBER:
347004314
ADMINISTRATOR:MATTHEW ENRIQUEZFACILITY TYPE:
735
ADDRESS:11586 BADGER COLONY COURTTELEPHONE:
(916) 687-8425
CITY:WILTONSTATE: CAZIP CODE:
95693
CAPACITY: 6CENSUS: 4DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Thelma CasugayTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct the annual inspection. LPA met with Designated Co-Administrator Thelma Casugay and stated the purpose of today’s visit.  LPA Valerio was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility that is licensed to serve a total capacity of 6 clients. Facility Staff Ben confirmed residents and staff have not shown any signs of COVID-19 in the last 10 days.

The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility submitted a LIC 808 mitigation plan. LPA observed the facility to have a first aid kit, hand washing signage, and COVID - 19 informational signage posted at the front door and throughout the facility. The facility has a thermometer in the front of the entry way along with an automatic sanitizer dispenser. The facility is able to designate and dedicated a Covid-19 bedroom and bathroom if needed.

LPA observed the temperature inside the facility was measured at 68*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C). The hot water was measured at 118.9 *F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility was observed to have nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The centrally stored medications area, sharps, and chemicals were observed be locked and inaccessible to clients. LPA Valerio observed fire extinguisher(s) with last check on 01/21/21, smoke and carbon monoxide detectors, central heating and air in the facility.

LPA requested facility documentation: LIC 500, LIC 308, Liability Insurance, LIC 610E, bacteriological analysis, and surety bond

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited.  Exit interview held, copy of report given to Designated Co-Administrator Thelma Casugay.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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