347005412-7-26-2023-59-AS-DAWL-CU4SVM-20230726141257

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005412
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:13:06 PM

Document Has Been Signed on 07/26/2023 02:13 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	VIRGINIA DENISE COUNTRY HOME		FACILITY NUMBER:	347005412
ADMINISTRATOR:	FERMO, AILEEN		FACILITY TYPE:	740
ADDRESS:	2305 VIRGINIA DENISE LANE		TELEPHONE:	(916) 813-0460
CITY:	RIO LINDA	STATE: CA	ZIP CODE:	95673
CAPACITY:	6	CENSUS: 4	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:44 PM
MET WITH:	Aileen Cantor Fermo, Administrator		TIME COMPLETED:	02:45 PM

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On July 26, 2023 at 12:45pm, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an annual inspection. LPA met with Aileen Fermo, Licensee, and advised her the reason for the visit. The Administrator's Certificate is current and expires October 2025.

LPA and Aileen completed the Infectious Control questionnaire with no issues or advisories. The Infectious Control Plan is currently in affect. LPA and Aileen toured the home. There are no bodies of water on the premises. The smoke alarm was working. The Medication Administration Record was viewed and found to be completed. The facility's temperature was 75 degrees.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. There’s appropriate lighting throughout the facility.
Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be enough and in good repair. Resident bedrooms and bathrooms were toured.

To continue see 809-C...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VIRGINIA DENISE COUNTRY HOME	FACILITY NUMBER: 347005412
	VISIT DATE: 07/26/2023

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Bedrooms had all the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer were present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible.

First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. This facility sits on 2 acres and the backyard is currently being landscaped.

There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current.

Staff records reviewed indicated current First Aid & CPR certificates. Facility is conducting staff training as required. LPA reviewed 2 client files. Files had the the proper updated documents in them. Because 2 clients were in Day Program, there were not able to be interviewed. The other 2 clients were not able to be interviewed due to the lack of understanding of what's being asked.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed.

****The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than August 25, 2023.*******

A copy of this report was given to Aileen.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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