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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570314689
Report Date: 06/18/2021
Date Signed: 06/18/2021 12:17:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SACRED HEART CARE HOME FOR THE ELDERLYFACILITY NUMBER:
570314689
ADMINISTRATOR:DAVIS, ARVINFACILITY TYPE:
740
ADDRESS:605 CONNOR LANETELEPHONE:
(530) 662-6055
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:8CENSUS: 6DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Walters conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was greeted by staff. Administrator, Arvin Davis was unavailable. LPA conducted a Risk Assessment prior to entering.

LPA arrived and was screened for COVID symptoms using an IPAD. LPA/Staff then conducted a tour of the facility. LPA observed that the facility was a comfortable temperature. Resident's rooms were furnished per regulation. Medications are centrally stored in the living room cabinet. Facility has a 30-day supply of medication for residents. Facility Administrator Certificate for Administrator Arvin Davis 6048451740 , expires 10/13/2021.

Facility has submitted a mitigation program plan that was approved on 5/24/21. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored daily. Facility has additional PPE supplies stored in the living room cabinets. Residents do not typically wear masks inside the facility but have them available. All staff had masks on during this visit. During the inspection residents were engaged in games and other activities for entertainment. Licensee will submit updated copies of the following documents by 6/21/21: Updated facility sketch

No deficiencies were cited during today's inspection.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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