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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004012
Report Date: 09/07/2021
Date Signed: 09/07/2021 04:08:34 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:RIVER FOUNTAINS OF LODIFACILITY NUMBER:
397004012
ADMINISTRATOR:REBECCA COBBFACILITY TYPE:
740
ADDRESS:311 WEST TURNER ROADTELEPHONE:
(209) 334-3763
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:80CENSUS: 56DATE:
09/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Rebecca Cobb, AdministratorTIME COMPLETED:
02:35 PM
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On 09/07/2021 at 8:50 am, Licensing Program Analyst (LPA) T. White contacted facility staff, regarding facility risk assessment questions. Facility staff confirmed no staff or clients have experienced symptoms within the last 10 days. At 1:05 pm, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Administrator, Rebecca Cobb and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 80 non-ambulatory residents which 7 may be on hospice.

LPA toured the facility including but not limited to apartments, bathrooms, kitchen, common area, and courtyard. All outdoor and indoor passageways are kept free of obstruction. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ bathrooms was measured at 115, 116.8 and 114.1 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

LPA observed smoke detectors and carbon monoxide is interconnected with the fire department. Fire extinguisher was last serviced on 06/01/2021. LPA observed mitigation plan is complete. LPA observed 3 isolation rooms accessible to residents in care. Fire drill last conducted on 06/30/2021.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/14/2021:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
No deficiencies cited during inspection. Exit interview conducted with Administrator and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
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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