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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005391
Report Date: 06/06/2022
Date Signed: 06/06/2022 01:30:46 PM


Document Has Been Signed on 06/06/2022 01:30 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:CARE HORIZONS ASSISTED LIVINGFACILITY NUMBER:
347005391
ADMINISTRATOR:IORDACH-STIR, ADRIANNAFACILITY TYPE:
740
ADDRESS:6630 CARE LANETELEPHONE:
(916) 721-2073
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
06/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adriana Iordache-StirTIME COMPLETED:
01:00 PM
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On 6/6/22, Licensing Program Analyst (LPA) Kevin Mknelly, conducted an unannounced case management, Health and Safety monitoring check. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened with temperature and symptom check at the facility.
Current six(6) residents were found to be well attended by caregiver on staff. Facility was clean and odor free. LPA reviewed files for 3 of 6 residents. Files are in order. LPA reviewed 1 of 2 care giver files. File and training are in order.


LPA advised Licensee seek a exception if they wish to have more that 1 resident under 60, record more detail for training records, ensure care plans are updated annually for all residents and rectify the LIC 602 for R1 to correct that they are not bedridden.

As a result of the this visit, no deficiencies are noted.


Report reviewed and copy and appeal rights provided
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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