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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005261
Report Date: 01/31/2022
Date Signed: 01/31/2022 03:28:06 PM

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:RNCARE HOUSE @ CARMICHAELFACILITY NUMBER:
347005261
ADMINISTRATOR:ESTANTE, EDWARDFACILITY TYPE:
740
ADDRESS:3120 COLORADO ST.TELEPHONE:
(916) 283-6516
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Hazel EstanteTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang, arrived at the facility unannounced on 1/31/2022 to conduct an unannounced Required-1 Year Inspection using the infection control tool. LPA met with Co-Administrator Hazel Estante, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive COVID-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA was screened by Co-Administrator.

LPA and Co-Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, kitchen, laundry room and common restrooms. LPA advised Co-Administrator to have trash can with lid in all restrooms. LPA observed (1) resident in the common area and (3) residents in their private rooms. Inside temperature was observed to be 72* F. Fire extinguisher last serviced 1/6/2022. LPA's observed 2+day perishable and 7+day non-perishable food and all sharps and toxins to be locked. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed expired Administrator certificates #6004981740 (exp 11/9/2021) and #6007976740 (exp 12/27/2021) posted.
LPA reviewed (1) resident’s records. Resident records were found to be current.

LPA requested a current copy of liability insurance by 2/4/2022.

Per California Code of Regulations, Title 22, the following deficiencies were cited from today's inspection. See LIC-809-D for deficiencies.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: RNCARE HOUSE @ CARMICHAEL
FACILITY NUMBER: 347005261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(d)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documentation reviewed and Co-Administrator's statement, the licensee did not ensure that either Administrator completed the required continuing education hours prior to the expiration of their administrator certificates which poses a potential health and safety risk to residents in care. Administrator Certificates expired on 11/9/2021 and 12/27/2021.
POC Due Date: 03/04/2022
Plan of Correction
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Licensee will submit proof of the application of recertification to CCL by the POC date of 03/04/2022.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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