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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005168
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:05:17 PM


Document Has Been Signed on 07/06/2022 12:05 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, 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:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Harue SekiTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 07/06/2022 at 11:27 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 six non-ambulatory residents. There are currently 6 residents who reside at this facility. The facility has a hospice waiver for three residents.

LPA Martinez toured the facility with Harue Seki and Hidenori Seki on 07/06/2022 at 11:30 PM.

The facility has submitted a LIC 808 Covid-19 Mitigation Plan and there are Covid-19 postings throughout the facility. The facility has a 30 day supply of PPE. The facility has a designated area for visits. Additionally, the facility has one main screening entry point. The facility conducts daily cleaning. The facility temperature was 76 degrees. The facility has an adequate food supply. The facility smoke/carbon detectors are in good repair. The facility fire extinguisher was last inspected in March of 2022.

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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