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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 09/14/2022
Date Signed: 09/20/2022 09:58:23 AM


Document Has Been Signed on 09/20/2022 09:58 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:SAMARITAN VILLAGEFACILITY NUMBER:
507002396
ADMINISTRATOR:RIKKI PEREZCHICAFACILITY TYPE:
740
ADDRESS:7700 FOX ROADTELEPHONE:
(209) 883-3000
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY:277CENSUS: 179DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rikki PerezchicaTIME COMPLETED:
01:00 PM
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Unannounced annual visit made out to this facility on 09/14/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Rikki Perezchica who was briefly interviewed at this time.
It was learned that there were currently (7) residents under the care of hospice at this time. This facility was granted a hospice waiver to be able to accept and retain up to 15 residents under the care of hospice at any given time.
It was learned that there were currently 10-15 residents under the care of home health at this time.
Current census was 179 residents spread out over several buildings and multiple floors of this facility campus.
Tour of the main facility building was conducted for the first and second floors alongside the facility designated Administrator Rikki Perezchica.
Living areas, dining areas, and all other areas intended for resident use were toured.
A sample of the resident rooms for both floors was toured. Resident furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A review of the resident restrooms was conducted. Grab bars and non skid surfaces were observed to be present and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 03/02/2022 by the local fire extinguisher company, Cisco Fire, and in compliance at this time.
Main medication room was toured on the first floor. Policies and procedures were discussed with the facility medication technician in terms of handling, dispensing, and documentation of all medications for the residents.
First aid kit was observed to be present and contained all of the necessary components at this time.
A tour of the facility kitchen area was conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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: 09/14/2022
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Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at all times. Food storage units were toured. It was learned that all meals were mainly prepared in this kitchen and then transported to the residents in other buildings and multiple floors as needed.
Laundry area was toured. It was observed that this area was locked and made inaccessible to the residents at this time.
Storage rooms were toured.
Exterior grounds of this facility was toured. A review of the facility perimeter fence, side gates, and all exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL at this time:
  • 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: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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