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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005391
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:15:14 PM


Document Has Been Signed on 06/09/2022 04:15 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: 5DATE:
06/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Adriana StirTIME COMPLETED:
04:20 PM
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On 06/09/2022 at 3:05 pm, Licensing Program Analyst (LPAs) Cassie Yang and Kevin Mknelly arrived to the facility unannounced and spoke with caregivers, Mazia Martin and Marlene Scarlett. Marlene Scarlett contacted Administrator, Adriana Stir, who arrived at the facility shortly afterwards. LPAs 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.

The purpose of this inspection was to conduct a records review as a response of the death incident reported to LPA Mknelly on 06/08/2022 by Administrator.

LPAs ensured the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by caregiver, upon entering the facility.



LPAs requested to review R1's file and medical records. LPAs conducted a tour of the facility and observed (5) residents to be present and were informed there are (0) no residents on hospice services.

LPAs requested and obtained a copy of R1's Doctor's Visit Care Notes, ID/Emergency Form, Preplacement Appraisal, LIC 622A and LIC 602A by Administrator.

No deficiencies are being cited as a result of today's inspection.



LPAs reviewed this report with Administrator and provided a copy.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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