<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005714
Report Date: 04/26/2022
Date Signed: 04/26/2022 03:28:04 PM


Document Has Been Signed on 04/26/2022 03:28 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 LIVING IIFACILITY NUMBER:
347005714
ADMINISTRATOR:IORDACHE-STIR, DRAGOS A.FACILITY TYPE:
740
ADDRESS:6640 CARE LANETELEPHONE:
(916) 550-1500
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Adrian Iordache, Administrator TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with caregiver, Adrian Iordache, Administrator and explained purpose of inspection. LPA observed caregivers, Carmeta Hamilton and Karlene Brown to be present also and wearing masks. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols 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: KN95 mask. LPA observed (2) residents in the common area watching television and (2) residents to be in their rooms. There aer currently (0) residents on hospice services.

LPA and Administrator toured the interior and exterior of the facility, including (2) private resident bedrooms, (2) shared resident bedroom, (2) bathrooms, kitchen, common areas, locked laundry area, staff room and garage/storage area. LPA observed all areas toured to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 72* F. Fire extinguisher last serviced 7/17/2021. LPA observed locked toxins, medications and sharps in the and sufficient 2+day perishable/7+day non-perishable food. First aid kits on site. Smoke/ monoxide in working order. Exit doors have alarms on them. LPA observed paper towels, soap, sanitizer, and hand-washing posters in the bathrooms and sufficient PPE supply and incontinent products, activities, and books. There is (1) large outside private vehicle gate to the entrance of the street. RCFE Administrator cert exp 11/13/2022. LPA observed various Covid posters throughout as well as other required postings. Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols per PIN 22-07.
Discussed scheduling booster shots for residents when eligible. All staff are cleared/associated.

LPA requested an updated copy of LIC500 and a copy of the current liability insurance by 5/8/22. Exit interview. There were no deficiencies observed during today's inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1