<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005926
Report Date: 07/21/2021
Date Signed: 07/21/2021 07:13:22 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:LAKE VIEW VILLAFACILITY NUMBER:
577005926
ADMINISTRATOR:MADRIAGA, STANFORDFACILITY TYPE:
740
ADDRESS:3865 COLLINS STREETTELEPHONE:
(916) 873-8633
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:6CENSUS: 4DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Stanford Mariaga, AdministratorTIME COMPLETED:
07:20 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
Licensing Program Analysts (LPAs) Katrina Walters and Jill Nakagawa arrived unannounced to conduct an Annual Required inspection and met with Stanford Mariaga, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPAs observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, disposable mask and a sign-in sheet for visitors. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff and client's temperatures are taken 2 times a day and is documented. LPAs conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. Staff clean and disinfect the facility daily. High touched surface areas are disinfected after each use. The facility has a designated visitation area, provides virtual visits and phone calls for family to stay in contact with clients.

Administrator stated staff are surveillance tested for COVID-19 as a precaution.LPAs observed 4 clients in care. Facility staff have completed training on infection prevention, symptoms, transmission and PPE use. N-95 respirator Fit testing was done. LPAs observed a 60+ day supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. All of staff wore a face mask during this visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services. Exit interview conducted with Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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 1