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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005726
Report Date: 05/11/2022
Date Signed: 05/11/2022 12:48:08 PM

Document Has Been Signed on 05/11/2022 12:48 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WHISPERING PINE IIFACILITY NUMBER:
097005726
ADMINISTRATOR:SEREDA, IRINAFACILITY TYPE:
740
ADDRESS:923 APERO PLACETELEPHONE:
(916) 293-8598
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 5DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Helen Guzuvaty, CaregiverTIME COMPLETED:
01:00 PM
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On May 11, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an annual Inspection. LPA met with Helen Guzuvaty, Caregiver and informed her the reason for the visit.
Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

Helen and LPA conducted the infectious control questionnaire with no issues.

LPA observed the following: Administrators Certificate is valid expiring December 2023. Fire extinguishers fully charged. Smoke detector and Carbon Monoxide detector are functional. Facilities temperature measured 70 degrees F. Common areas were clean and in good repair. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. The facility is a 6 bed home. All rooms had the required furniture and lighting. All residents have had their vaccinations and boosters.

Per California Code of Regulations, Title 22, no deficiencies were observed.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional office.. Administrator shall submit the listed documents to Licensing no later than June 11, 2022.

Exit interview with was conducted and a copy of this report was left with Helen.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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