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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340313161
Report Date: 10/05/2022
Date Signed: 10/05/2022 04:25:56 PM

Document Has Been Signed on 10/05/2022 04:25 PM - 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, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833
FACILITY NAME:DEBORAH FILPULA FAMILY HOMEFACILITY NUMBER:
340313161
ADMINISTRATOR:FILPULA, DEBORAH M.FACILITY TYPE:
710
ADDRESS:10496 DREXEL COURTTELEPHONE:
(916) 366-3432
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 5CENSUS: 6DATE:
10/05/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Deborah Fipula, AdministratorTIME COMPLETED:
04:40 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 Analyst (LPA) Yuvi Diaz made an unannounced annual inspection on October 5, 2022, at 12:30PM. During the inspection LPA met with Mathew Fipula, DSPII and Frank Faukener, DSPII who assisted with the inspection.

LPA Diaz conducted a walk-through of the facility inside and out. LPA Diaz interviewed two staff members and one client. LPA Diaz observed six bedrooms, and four bathrooms.LPA Diaz inspected and/or reviewed the following:

I. Physical Plant: Posting of license, Personal Rights, Covid Poster, Facility Sketch, Client Roaster, and Emergency Disaster Plan. Disinfectants/Cleaning solutions inaccessible, Refrigerator Temperature at or below 45 degrees F 45 Freezer Temperature at or below 0 degrees 0. Nonperishable Foods one week and fresh perishable foods two days minimum. Menu present and posted, Working telephone. Carbon monoxide detectors and Smoke Detector were all in working condition. First Aid Kit fully stocked. Common Room available, Dining area with enough seating, furniture good condition. Medication centrally stored, locked/inaccessible. Fire Extinguisher has been serviced. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature. Soap and Paper towels in all bathrooms. Bedrooms had all the required linen and furnishings. Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts.

II. Operations: Complaint Procedures for Youth Reviewed. Disaster and mass casualty plan was available for review. However, it has not been updated. TA. Quarterly Drills conducted and documented
Report continues on LIC 809-C
SUPERVISORS NAME: Rosa Rodriguez
LICENSING EVALUATOR NAME: Yuvicela Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833
FACILITY NAME: DEBORAH FILPULA FAMILY HOME
FACILITY NUMBER: 340313161
VISIT DATE: 10/05/2022
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
26
27
28
29
30
31
32
III.Staffing/Volunteers: Number of Staff files reviewed four including administrator. Criminal record clearances verified,First Aid Certificate, Certified Administrators certificate valid and current ,Job title/qualification verified, required training verified, and 40 Hours required annual training verified.

IV: Client Records" Number of Clients files reviewed three. Files had Needs and Services Plan, Centrally Stored Medication and log reviewed. Psychotropic Medication and log reviewed, Cash Resources.

No deficiencies were noted at today's visit. One Technical Advisory's was given.

An exit interview was conducted with Deborah Fipula, Administrator and a copy of this report was emailed.
SUPERVISORS NAME: Rosa Rodriguez
LICENSING EVALUATOR NAME: Yuvicela Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2