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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004650
Report Date: 04/22/2022
Date Signed: 04/22/2022 12:27:59 PM

Document Has Been Signed on 04/22/2022 12:27 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:BUENA VISTA HOME IIFACILITY NUMBER:
347004650
ADMINISTRATOR:ASTRONOMO, REYFACILITY TYPE:
735
ADDRESS:6350 MARIPOSA AVENUETELEPHONE:
(916) 727-7273
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 4DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Melody Bulanadi, staffTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/22/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with staff, Melody Bulanadi and explained the purpose of the visit. 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 and contacted administrator 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: surgical mask. Additionally, LPA was screened by staff upon entry.

Administrator was contacted upon LPA's arrival but was unable to come to the facility for the inspection, administrator gave verbal permission for visit to be completed with staff.

LPA and staff toured facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, brief inspection of four clients rooms, two bathrooms, kitchen, medication closet, laundry area, garage, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and staff completed the infection control domain together 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 and copy of report left at the facility.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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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