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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005926
Report Date: 05/31/2022
Date Signed: 05/31/2022 10:54:18 AM


Document Has Been Signed on 05/31/2022 10:54 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Stanford Madriaga, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required Inspection and met with Administrator Stanford Madriaga. 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 to be answered before being allowed to remain in 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 of 75 F with all exits free from obstruction. Toxins are stored in locked laundry room. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored and locked in closet making them inaccessible to residents and staff that do not handle medications. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment (PPE). Administrator and staff had a mask on during the LPA's inspection. There is an approved hospice waiver for five (5) residents. Mitigation plan was approved by the Department on 08/04/21. Fire clearance is approved for six (6) non-ambulatory, which includes one (1) bedridden.
There were four (4) residents in care at the facility during this inspection.

No deficiencies during today's inspection.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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