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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005864
Report Date: 07/27/2021
Date Signed: 07/27/2021 05:08:32 PM

Document Has Been Signed on 07/27/2021 05:08 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:QUEEN OF HEARTS ELDERCAREFACILITY NUMBER:
347005864
ADMINISTRATOR:SOHANI, MARGIEFACILITY TYPE:
740
ADDRESS:9464 OAK AVETELEPHONE:
(916) 988-6764
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 14CENSUS: 11DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cindy Soto, Assistant AdministratorTIME 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) Wolter arrived at the facility unannounced on 07/27/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Assistant Administrator Cindy Soto and explained the purpose of the visit. Prior to initiating the annual inspection, 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 and contacted facility and 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 completed the facility's screening protocols upon entering the facility.

LPA and Assistant Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, brief inspection of resident bedrooms, resident bathrooms, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

Administrator Margie Sohani arrived later during inspection. LPA, administrator and assistant administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report emailed to administrator.

Administrator to send the department copies of the following documents: LIC 808 - Mitigation Plan, LIC 500 - Personnel Report, and a current copy of liability insurance by 08/03/2021.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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