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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004314
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:56:41 PM

Document Has Been Signed on 01/03/2024 03:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 6DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Matthew EnriquezTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 1/3/2024 at 2:00pm.

LPA met with Cheenei Sidney, Caregiver who contacted the Administrator Matthew Enriquez regarding the purpose of todays visit. Matthew Enriquez, Adm arrived within 15 minutes to assist with todays visit. The facility is licensed for a capacity of 6 residents of which 5 maybe non-ambulatory and 1 maybe bedridden.
LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. Administrator Certificate expires 7/2/2025.

The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 116.7*F which is within the required range of 105-120*F. LPA observed pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the P&I monies for Resident #1 (R1) to be counted, documented and not commingled during this visit. The most recent emergency drill was conducted on 12/7/23.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JO BIGORNIA HOME WILTON
FACILITY NUMBER: 347004314
VISIT DATE: 01/03/2024
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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Current
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-Current
Surety Bond LIC402-Current
Facility Floor Plan/Plot Plan LIC999-Current
Fire Clearance (consistent with terms and limitations of license)-Current
Qualifications of Administrator/Facility Manager-Submit
Articles of Incorporation/Organization, Constitution and bylaws-Current
Partnership Agreement-NA
Control of Property-Submit
Emergency Disaster Plan LIC610-Submit
Plan of Operation (Restricted Health Care Plan)-Current
Admission Policies and Procedures-Current
Health Screening Report-Facility Personnel LIC503-Current
Bacteriological Analysis of Private Water Supply-Submit
In-service Training Program-Current
Medication Procedures-Current
Transportation Procedures-Current
Job Description/Personnel Policies-Current
Exemptions/Waivers and Exceptions-Current
First aid/CPR certificates-Current

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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