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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 09/09/2021
Date Signed: 09/14/2021 02:02:07 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:SAMARITAN VILLAGEFACILITY NUMBER:
507002396
ADMINISTRATOR:RIKKI PEREZCHICAFACILITY TYPE:
740
ADDRESS:7700 FOX ROADTELEPHONE:
(209) 883-3000
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY:277CENSUS: 178DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rikki PerezchicaTIME COMPLETED:
02:00 PM
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Unannounced annual visit made out to this facility on 09/09/2021 by this LPA who was met by the facility designated Administrator, Rikki Perezchica, who was briefly interviewed at this time.
Current census was 178 residents.
This facility is licensed to serve and accept up to 277 residents who are deemed to be ambulatory and non ambulatory as well. This facility is composed of (3) separate buildings with multiple floors as well. All buildings are controlled through key cards and passcodes for entry.
Tour of the facility campus was conducted.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. It was learned that kitchen staff are separate in terms of duties and did not double as care providers.
Food storage units, facility refrigerator unit and freezer unit, were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time. Pantry area housing dry goods and products was toured. Medication rooms, located in each building, were toured. Policies and procedures were discussed with the medication technicians at this time in regards to dispensing, documenting, and communication for all involved parties. Medication carts were being used with narcotic lock boxes and separate refrigeration units for such medications.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to have been annually inspected on 03/24/2021 by the local fire equipment company and found to be in compliance at this time.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and in compliance at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. Grab bars and non skid mats/surfaces were observed to be present and in good repair at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SAMARITAN VILLAGE
FACILITY NUMBER: 507002396
VISIT DATE: 09/09/2021
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Activity center was toured as well.
Linen supplies were reviewed and observed to be in compliance at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence, side gates, and exterior exits was conducted.

This LPA requested the following forms and documents from this facility to be updated and submit into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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