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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004611
Report Date: 12/10/2021
Date Signed: 12/10/2021 10:59:46 AM

Document Has Been Signed on 12/10/2021 10:59 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:V & P TRUONG CARE HOME, LLCFACILITY NUMBER:
577004611
ADMINISTRATOR:TRUONG, VANFACILITY TYPE:
735
ADDRESS:3755 CASTAIC COURTTELEPHONE:
(916) 372-8033
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY: 4CENSUS: 4DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Van Truong, Licensee/AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted 1 year required inspection and met with Administrator/ Licensee Van Truong. The inspection is focused on the Infection Control procedures and practices of this facility.

All visitors, essential visitors, and staff are screened upon entry; temperatures are taken, and screening questions are answered before being allowed to enter the facility, all information is logged. Residents are screened and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Water temperature was tested and within 105 -110 degrees F in 3 out of 3 faucets. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents. Exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. Facility has a sufficient supply of personal protective equipment (PPE). Administrator/Licensee and staff had a mask on during the LPA's inspection. Facility has 4 residents. Mitigation plan was approved by the Department on 03/05/21. Fire inspection was done on 12/02/21 with no violations.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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