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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005109
Report Date: 07/06/2022
Date Signed: 07/06/2022 11:19:55 AM


Document Has Been Signed on 07/06/2022 11:19 AM - 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:AMERICAN RIVER CARE HOME 2FACILITY NUMBER:
347005109
ADMINISTRATOR:HARUE SEKIFACILITY TYPE:
740
ADDRESS:2801 TIOGA WAYTELEPHONE:
(916) 283-6716
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 6DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Harue SekiTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 07/06/2022 at 10:20 AM. LPA met with Harue Seki and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for five non-ambulatory residents and 1 ambulatory resident. There are currently 6 residents who reside at this facility. The facility has a hospice waiver for 2 residents.

LPA Martinez toured the facility with Harue Seki on 07/06/2022 at 10:30 AM.

The facility has submitted a Covid-19 Mitigation Plan. The facility has a main entry screening point. The facility has covid posting throughout the facility. The facility conducts disinfecting cleaning daily, and the facility is sanitary. The facility has a designated area for visit. The common facility furniture spaced 6 feet apart. Fire extinguisher is good in repair. Smoke and Carbon detector are in good repair.

There were no deficiencies observed at this annual inspection. LPA Martinez conducted an exit interview, and a copy of this report was given to Harue Seki.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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