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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 08/04/2021
Date Signed: 08/04/2021 02:30:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PLACE CALLED HOMEFACILITY NUMBER:
392701008
ADMINISTRATOR:VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(714) 948-0381
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: 10DATE:
08/04/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Brandi VargasTIME COMPLETED:
02:40 PM
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On 8/4/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct POC visit to the facility to verify correction of citations issued during the Post Licensing Inspection conducted on 07/28/2021. LPA contacted Administrator Brandi Vargas for COVID questionnaire to confirm no staff or residents show symptoms of COVID. LPA was allowed entry into the facility that is licensed to serve a total capacity of 11 residents. Today's census 10.

Four of five deficiencies cited under Title 22 Regulations have been cleared:87618(b)(3)(B),87465(h)(2), 87465(a)(5) and 87303(a). Licensee complied with the terms of the POC by POC due date. Declarations not found to submitted to the Regional Office of POCs due on 7/29/2021, proof of fax receipt reviewed by LPA. Date on fax machine is incorrect and LPA provided recommendation to correct the date for documenting accurate record keeping. LPA left POC letters during today's visit for the above citations.

One of five deficiencies cited under Title 22 Regulations the facility did not comply with: LPA observed hot water measured at kitchen sink at 137.5*F, staff restroom at 135.7*F, and residents restrooms at 130.1 *F, 130.6*F,133.0*F and 122*F. The facility has been taking water temperature since 7/28/2021 at kitchen sink but the thermometer is not in working order. Temperatures recorded at 118*F. Administrator stated they will purchase a thermometer in working order. The facility will be assessed civil penalties for failure to correct this citation. Attached is the LIC 421 FC.

Exit interview conducted, a signature on these forms acknowledges receipt and a copy was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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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