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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701015
Report Date: 07/29/2021
Date Signed: 07/29/2021 12:20:27 PM

Document Has Been Signed on 07/29/2021 12:20 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:MOTHER CONCHING LLCFACILITY NUMBER:
312701015
ADMINISTRATOR:GOMEZ, MARCOFACILITY TYPE:
740
ADDRESS:7253 LIVERPOOL LANETELEPHONE:
(916) 365-7994
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 3DATE:
07/29/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marco Gomez, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Praveen Singh arrived to conduct an announced Pre-Licensing inspection. LPA met with Administrator Marco Gomez and explained the purpose of the visit. Co-Administrator John Paul Pamintuan was also present during inspection. Prior to initiating the Pre-Licensing 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 Facility Representative and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by John Paul Pamintuan upon arrival.

This Pre-Licensing is relative to facility's change of ownership. This facility currently has 3 residents and is operating under license number 317004917. LPA and administrator toured the facility and common areas, activity room, dining room, kitchen, backyard and resident rooms were inspected. Facility has six (6) private resident bedrooms, and three (3) resident bathrooms. Bathrooms were equipped with grab bars and non-skid mats and hot water temperature measured at 106.3 degrees F. Bedrooms were equipped with required furniture and smoke detectors and carbon monoxide detectors were present. Fire extinguisher was observed to be fully charged and last serviced on 2/11/21. Facility's fire clearance was granted on 7/6/21. LPA observed a sufficient 2-day supply of perishable and 7-day supply of non-perishable foods. LPA observed there are adequate amounts of linens, towels, and dishes at the facility. LPA observed locked cabinet for sharps, toxins, and centrally stored medications. First aid kit was found to be complete. LPA reviewed sample staff and resident files and found required forms to be in the files. Administrator stated that disaster drills will be completed and documented at minimum every three months.


[See LIC809-C for Continued Report]
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MOTHER CONCHING LLC
FACILITY NUMBER: 312701015
VISIT DATE: 07/29/2021
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LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and copy of report provided.

[See LIC809 (Case Management Report) dated 7/29/21, for Comp III Review Conducted today]
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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