<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004314
Report Date: 11/29/2022
Date Signed: 11/29/2022 12:45:29 PM

Document Has Been Signed on 11/29/2022 12:45 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, 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: 5DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Thelma Enriquez - AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Staff confirmed staff and residents have not displayed any signs or symptoms of COVID-19 in the last 10 days. LPA explained the purpose of visit to administrator.
 
LPA and direct care staff inspected physical plant inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. There were no observed health or safety concerns. The facility has an approved LIC 808 mitigation plan uploaded into FAS. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have COVID-19 informational and hand washing signs posted at the front door and throughout the facility. The facility is able to designated and dedicated a COVID-19 bedroom and bathroom if needed. Facility staff and Administrator are aware of recent PINS regarding vaccinations, boosters, and visitation.
 
LPA observed the temperature inside the facility was measured at 73.2*F. The hot water was measured at 107.8*F in kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to residents. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were last serviced on 1/14/2022.

LPA reviewed two (2) resident file and three (3) one staff member files. All staff are fingerprint cleared and have current first aid certificates. All residents have required documents for community care licensing (CCL).
 
Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with administrator and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1