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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700115
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:47:06 PM

Document Has Been Signed on 06/23/2022 02:47 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: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:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Facility staff-Shaneka Salman TIME COMPLETED:
03:00 PM
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Licensing Program Analyst Talwinder Bains arrived at the facility unannounced on 06/23/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. Upon arrival, LPA was told was told that administrator Gurdip Judge is out due to family emergency. Facility staff did get hold of facility staff Simran Bisla (Sue) via phone at 12.50pm and she told LPA over the phone that she is giving the permission facility staff Shaneka Salman to go over with annual inspection for today. LPA met with Shaneka and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by facility staff before entry to facility.

LPA and Shaneka toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas,five residents bedrooms , three bathrooms, medication closet , staff break room, garage, laundry room and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Shaneka completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today's inspection.
Exit interview conducted and copy of report left at the facility.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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