507003709-6-25-2021-27-AS-ABOE-C4BT52-20210625142450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003709
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:24:59 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:	CHANCELLOR MANOR		FACILITY NUMBER:	507003709
ADMINISTRATOR:	CLARITA RAMISCAL		FACILITY TYPE:	740
ADDRESS:	5707 CHANCELLOR WAY		TELEPHONE:	(209) 858-8830
CITY:	RIVERBANK	STATE: CA	ZIP CODE:	95367
CAPACITY:	6	CENSUS: 5	DATE:	06/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Terisita Newalu		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/23/2021 at 8:29am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Licensee, Clarita Ramiscal regarding facility risk assessment questions. Clarita confirmed no staff or residents have experienced symptoms within the last 10 days. At 1pm, LPA arrived unannounced to conduct a Required 1-year Annual inspection. LPA met with Staff one (S1) and explained the purpose of today’s inspection. S1 contacted Clarita, unable to come to the facility during today's inspection and designated S1. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 non ambulatory residents and hospice waiver for 3 in compliance with fire clearance and license. Today's census is 5 of which 3 are hospice. One of one staff observed with criminal record clearance and associated in Licensing Information System. LPA observed Administrator Certificate expires 10/16/2022. LPA interacted with a random number of residents during this visit and observed residents engaging in activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, restrooms, bedrooms, laundry room, storage areas and common living areas to be clean in good repair. LPA observed fence trellis on side yard not in use rusted and detaching from the fence. LPA observed personal care products and loofa in resident shared restrooms. The temperature inside the facility was measured at 79F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 107 F which is not less than 105 F and not more than 120*F. LPA observed the centrally stored medications, knives, laundry room and staff room to be locked inaccessible to residents. All medications observed properly stored and labeled and matching MAR's. The first aid kit was found in compliance containing at least the following: a current edition of approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed fire extinguisher last inspected on 1/8/2021, smoke and carbon monoxide detectors, central heating and air in the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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 4

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: CHANCELLOR MANOR	FACILITY NUMBER: 507003709
	VISIT DATE: 06/25/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed food supplies of properly stored and unexpired staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap and touchless covered trash can and 30 day supply of PPE stored of all items except N95 Respirators.

Upon a file review the following items were discussed to be submitted to LPA by 7/15/2021.
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Liability Insurance
Administrator Certificate
Emergency Disaster Plan LIC610E
Health Screening Report-Facility Personnel LIC503
First aid/CPR certificate

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report provided. A signature on these forms acknowledges receipt of documents.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4