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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003709
Report Date: 03/06/2024
Date Signed: 03/12/2024 10:25:30 AM


Document Has Been Signed on 03/12/2024 10:25 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CHANCELLOR MANORFACILITY NUMBER:
507003709
ADMINISTRATOR:CLARITA RAMISCALFACILITY TYPE:
740
ADDRESS:5707 CHANCELLOR WAYTELEPHONE:
(209) 858-8830
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY:6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Nicetas AbellaTIME COMPLETED:
03:30 PM
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Unannounced Plan of Correction visit made out to this facility on 03/06/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregivers. This LPA requested that they go ahead and contact the facility designated Administrator to inform him/her that CCL was present at this time. The facility designated Administrator arrived shortly thereafter to this facility while this LPA was conducting this plan of correction visit.
This visit was conducted to view and possibly clear the following deficiencies from a prior annual visit performed on 02/14/2024:
  • Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

  • To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

  • Each resident's record shall contain at least the following information:


A brief tour of the facility was conducted specifically for review of the above deficiencies. This LPA did observe that the plan of correction was completed by the due date.

There were no further deficiencies observed or cited during today's plan of correction visit.

Plan of correction clearance letters were printed and copies were provided to the facility designated Administrator at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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