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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:24:44 PM


Document Has Been Signed on 05/03/2024 01:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 176DATE:
05/03/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Rikki Perezchica, AdministratorTIME COMPLETED:
01:30 PM
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On 05/03/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility at approximately 8:45 am to follow up on the status of a city boil order. Upon arrival, LPA Campbell observed residents moving about and socializing. Water dispensers were observed available to residents, staff and guests.

On 04/26/24, LPA Campbell received an Unusual Incident Report from the facility that the City of Hughson was under a Boil Notice. LPA Campbell reviewed the memo and city announcement submitted to the residents. City residents were not to drink or use the water for food preparation without boiling. Samaritan Village informed the Department that the facility had 72 hrs of water supply. The Boil Notice ended the next day on 04/27/24 and the city notified Hughson citizens that testing had confirmed that the water was safe to use without boiling.

As stated by Administrator Rikki Perezchica, the city stated a well had depressurized and contaminated the water. The notice came from the city on Saturday that water could be used without boiling again. However, the facility did not come online until Sunday and used the extra day to flush the pipes. The kitchen removed all the ice and disinfected the water lines. During that time, ice was replaced, canned sodas were provided, and coffee was not served. Water use returned to baseline by Sunday morning.

The administrator also reported that the facility planned ahead for the boil notice to go on for an additional two days. To that end, the facility had three bins that are not connected to any water source that are filled and maintained to make sure there is water. In addition there were 5 gallon water dispensers that were spread around the campus for residents. More water bottles were also purchased in anticipation of a four day delay up until Tuesday. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's visit. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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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