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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005700
Report Date: 08/21/2024
Date Signed: 08/21/2024 01:42:12 PM

Document Has Been Signed on 08/21/2024 01:42 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FIORE HOMEFACILITY NUMBER:
347005700
ADMINISTRATOR/
DIRECTOR:		CARILLO, CHRISTIANFACILITY TYPE:
735
ADDRESS:11001 FIORE DRIVETELEPHONE:
(916) 376-7542
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 4DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Christian CarilloTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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On 8/21/24 at 10:31pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their required annual inspection visit. LPA initially met with staff on duty and stated the purpose of the visit. The Administrator Christian Carillo was notified of the visit and arrived shortly after. Present during today's visit were 2 staff. Clients in care were out in the community. Facility currently serves 4 ambulatory adult individuals.

LPA and Administrator inspected the physical plant of the facility. The facility is a one-story home located in a residential neighborhood. Front yard and backyard were observed to be clean and free of obstruction. LPA observed outdoor furniture for residents' use. Fences and gates were observed to be in good repair.

Four client bedrooms were inspected and observed to be clean and large enough space to accommodate client belongings. Facility has 1 bathroom for client use and observed to be clean and in good repair. The kitchen and pantry were inspected and observed to be sanitized and in good repair. Food supplies were stored properly. Facility maintains an adequate amount of food supply with 2-day perishables and 7-day nonperishables. Smoke detectors/carbon monoxide monitor combo were observed and tested and were found to be operable during this visit. Sharps, toxins and medications were observed to be locked and inaccessible to clients in care. Facility was observed to have adequate supply of linens for residents. Fire extinguisher was observed at the kitchen area near the stove and were last serviced on 7/3/24. Room temperature was at 78*F and hot water temperature was at 118*F in the client bathroom. Fireplace was observed to be inaccessible to clients and cased in glass.



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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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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Document Has Been Signed on 08/21/2024 01:42 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/21/2024 at 01:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FIORE HOME
FACILITY NUMBER: 347005700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. During a review of facility sketch, it was revealed that 2 staff rooms were added to the layout of the facility. At this time, there is no evidence of fire inspection ever conducted or fire clearance for the 2 staff rooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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- Licensee will read regulation 80020 and submit a signed declaration of understanding to LPA by POC due date.
- Licensee to submit an updated LIC 200 and proposed facility sketch to LPA by POC due date for processing of updated fire clearance. (Note: this part of the POC was submitted to LPA during this visit)

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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FIORE HOME
FACILITY NUMBER: 347005700
VISIT DATE: 08/21/2024
NARRATIVE
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LPA reviewed 4 of 4 client records and found to be in compliance at this time. LPA reviewed and counted, with Administrator, 2 of 4 residents' P&I money and found to be accurate. LPA reviewed 2 of 4 resident medications and found to be in compliance. LPA reviewed 4 personnel records and were found to be in compliance at this time with current 1st Aid/CPR certificates and background clearances. Facility conducts monthly emergency drills with last drill was conducted on 8/20/24. During a facility record review, it was found that Licensee made changes to the layout of the facility by adding 2 staff rooms. It is unclear if fire inspection was conducted prior to the construction. At this time, Administrator is unable to provide documentation of the fire inspection prior to the additional 2 staff bedrooms.

LPA requested copies of the following documents during this visit: current Liability Insurance Certificate, Surety Bond, LIC500, LIC308 and updated facility sketch.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. Civil penalties in the amount of $500 is issued today in addition to citations due to Fire Clearance violations. Note that failure to correct any deficiencies will result in additional civil penalties.

Exit interview held with Administrator, and a copy of this report and appeal rights were provided.












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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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