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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:21:47 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:
02/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Brandi VargasTIME COMPLETED:
12:45 PM
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On 2/9/22 , Licensing Program Analysts ( LPAs) Michael Bilger and Maja Jensen arrived at this facility unannounced to conduct a quarterly visit. LPAs were greeted by Nataley Martinez and LPA explained the purpose of the visit. LPAs verified there are no active COVID cases in the facility.
LPAs Michael Bilger and Maja Jensen inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 11-bed facility with a current census of 10. LPAs were screened upon entry for temperature and asked to sign in. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place and of an appropriate size. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. Administrator certificate posted and expires 9/1/22.
The facility has submitted a COVID mitigation plan. The facility has a central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPAs observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
Water temperature reads 105 in the bathroom. LPAs observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. First aid kit was observed as complete.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Brandi Vargas
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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