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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000981
Report Date: 03/12/2023
Date Signed: 03/12/2023 11:23:13 AM


Document Has Been Signed on 03/12/2023 11:23 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,
, CA



FACILITY NAME:JIM & LIZA'S CARE HOMEFACILITY NUMBER:
455000981
ADMINISTRATOR:HOLDEN, MERLINDAFACILITY TYPE:
740
ADDRESS:4929 HUNTINGTON DRIVETELEPHONE:
(530) 221-0220
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 5DATE:
03/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Merlinda Holden - AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met administrator and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; facility administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by administrator.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time.
LPA observed hot water temperature was measured at 107.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire Extinguishers were inspected on 5/12/2022 and in compliance. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed centrally stored medications locked up in medication rooms. LPA reviewed two (2) resident and two (2) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. One volunteer cook was not associated or fingerprint cleared for this facility. First aid kit was checked and is complete.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted with administrator. Copies of reports and appeal rights left with administrator.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2023
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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Document Has Been Signed on 03/12/2023 11:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: JIM & LIZA'S CARE HOME
FACILITY NUMBER: 455000981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in that fingerprinted staff from another community care licensed facility was not associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2023
Plan of Correction
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Licensee submitted letter stating all rules and regulations will be followed regarding fingerprint clearances for employees or volunteers. No further action required. Immediate civil penalty of $500.00 was assessed on 3/12/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2023
LIC809 (FAS) - (06/04)
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