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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005864
Report Date: 02/03/2022
Date Signed: 02/03/2022 01:43:13 PM

Document Has Been Signed on 02/03/2022 01:43 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: 10DATE:
02/03/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Administrator Margie SohaniTIME COMPLETED:
01:55 PM
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On February 3, 2022, at 1pm, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived to conduct an Annual Inspection. LPA met with Margie and Cindy the Licensee, and informed her of the reason for the visit. Prior to the inspection, LPA completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19, contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a Mask was worn for Personal Protective Equipment (PPE). Additionally, LPA was screened by staff upon arrival.

Cindy,the Administrator and LPA completed the inspection tool questionnaire with no issues or advisories to report.

LPA observed the following:
Administrator certificate is valid expiring . First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged.

Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6

See 809 -C...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ELDERCARE
FACILITY NUMBER: 347005864
VISIT DATE: 02/03/2022
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The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than March 3, 2022.

Exit interview conducted and a copy of this report given to Cindy.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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