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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004881
Report Date: 01/24/2024
Date Signed: 01/24/2024 12:26:28 PM

Document Has Been Signed on 01/24/2024 12:26 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ROSA CHICO'S CARE HOMEFACILITY NUMBER:
347004881
ADMINISTRATOR:CHICO, EVELYNFACILITY TYPE:
735
ADDRESS:8868 TIMM AVENUETELEPHONE:
(916) 390-8564
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 4DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Liwayway "Wendy" Chico, Acting AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 1/24/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are two (2) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 108.2 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed two (2) resident files and one (1) staff file. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 80087(g) regarding chemicals being accessible to residents. Deficiency is listed on 809-D.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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Document Has Been Signed on 01/24/2024 12:26 PM - It Cannot Be Edited


Created By: Michael Hood On 01/24/2024 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSA CHICO'S CARE HOME
FACILITY NUMBER: 347004881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the facility did not ensure that disinfectants and cleaning solutions were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
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Facility moved chemicals to a locked area during inspection. LPA cleared deficiency at the conclusion of today's inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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