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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700115
Report Date: 06/09/2021
Date Signed: 06/10/2021 08:16:45 AM

Document Has Been Signed on 06/10/2021 08:16 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WATERFORD RESIDENTIAL INCFACILITY NUMBER:
312700115
ADMINISTRATOR:JUDGE, GURDIPFACILITY TYPE:
740
ADDRESS:2588 WATERFORD CIRCLETELEPHONE:
(916) 213-2792
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Gurdip Judge (Admin)TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Konnor Lietzell arrived at the facility unannounced on 6/9/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Gurdip Judge (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection, 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. Additionally, LPA was screened by Stella Okolo (staff).

LPA and admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) of four (4) resident bedrooms, three (3) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time. LPA is to send facility additional documentation regarding FIT testing via email, and will deliver additional PPE supplies to fulfill 30 day supply.

LPA has requested the following documents to be submitted to CCLD by COB 6/18/2021:
  • Personnel Report (LIC 500)
  • Designation of Admin Responsibility (LIC 308)
  • Current Administrator Certificate
  • Proof of Liability Insurance
  • Emergency Disaster Plan (LIC 610)

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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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