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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005168
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:54:57 PM

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 HOMEFACILITY NUMBER:
347005168
ADMINISTRATOR:SEKI, HIDENORIFACILITY TYPE:
740
ADDRESS:3817 MARCONI AVETELEPHONE:
(916) 485-2172
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 6DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Harue Seki and Hidenori Seki. TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 07/29/2021 at 1:05 PM. LPA met with Harue Seki and Hidenori 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 six non-ambulatory residents. There are currently 6 residents who reside at this facility. The facility has a hospice waiver for three residents, which there are no residents receiving hospice services.

LPA Martinez toured the facility with Harue Seki and Hidenori Seki on 07/29/2021 at 2:20 PM.

LPA Martinez reviewed three employee files and three resident files. The employee and resident files are up to date. LPA Martinez reviewed 2 medication files. The medication files are up to date. The facility is furnished and sanitary. The facility smoke/carbon detectors are in good repair. The facility fire extinguisher was last inspected in March of 2021. he facility has a 2 day perishable and 7 day non-perishable food supply.The facility submitted a LIC 808 mitigation plan. The mitigation was approved. The facility has Covid-19 postings throughout the facility. The facility one central screen area.

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

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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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