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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004012
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:24:08 AM


Document Has Been Signed on 12/09/2022 11:24 AM - 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, 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:
12/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Rebecca CobbTIME COMPLETED:
11:42 AM
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On 12-9-22 at 10:17am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding facility billing procedures for resident1 (R1). LPA met with Administrator Rebecca Cobb and explained the purpose of the visit. LPA conducted interview with Administrator, R1's responsible party, and reviewed invoices for R1. LPA also reviewed regulation section 87464(e). Based on interview and record review, it was determined that R1 became a social security income (SSI) recipient as of 6/28/22 and was billed facility's basic service rate after this date.

Based on interview with Administrator, facility corporate billing office is now in the process of adjusting R1's invoice to reflect the proper amounts to be billed for R1 and send the revise invoice to R1's responsible party. Additionally, Administrator is in process of revising Admission agreement for R1 to reflect new amounts to be billed. Adjustments as noted above shall be completed within one week of the date of this report. Administrator is also in process of following up on R1's status for the assisted living waiver program.

LPA will return at a later date to conclude this case management visit. No deficiencies cited at this time. An exit interview was conducted with Rebecca Cobb and a copy of this report was left with Rebecca.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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