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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004524
Report Date: 07/01/2021
Date Signed: 07/01/2021 03:48:02 PM

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:SEFORA'S HOME CAREFACILITY NUMBER:
347004524
ADMINISTRATOR:SEFORA NICULAIFACILITY TYPE:
740
ADDRESS:6530 NOEMI LANETELEPHONE:
(916) 218-8355
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 5DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Cornelia Handolescu, staffTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/01/2021 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 contacted administrator and completed a facility risk assessment prior to inspection.

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 staff Cornelia Handolescu (S1) and explained the purpose of the visit. S1 screened LPA and contacted administrator and informed her of LPAs presence, administrator gave LPA verbal permission to complete inspection with S1.

LPA and S1 toured the home together, areas toured include but are not limited to: common areas, kitchen, resident bedrooms, bathrooms, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and administrator completed the infection control domain together over the phone and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted with S1 and copy of report to be emailed to administrator.

Administrator to send Community Care Licensing (CCL) updated copies of liability insurance, LIC 500 - Personnel Report,and LIC 308 - Designation of Facility Responsibility by 07/08/2021.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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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