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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701015
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:38:31 AM

Document Has Been Signed on 07/13/2022 11:38 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:MOTHER CONCHING LLCFACILITY NUMBER:
312701015
ADMINISTRATOR:GOMEZ, MARCOFACILITY TYPE:
740
ADDRESS:7253 LIVERPOOL LANETELEPHONE:
(916) 365-7994
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 4DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Marco GomezTIME COMPLETED:
11:45 AM
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Licensing Program Analyst Talwinder Bains arrived at the facility unannounced on 07/13/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator ,Marco Gomez and Co-Administrator John Paul Pamintuan (John) was also present during inspection. Prior to initiating the inspection, LPA 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. LPA confirmed that facility does not any covid-19 case and nobody showing any symptoms of covid-19 before facility entry. 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 John toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, 6 residents bedrooms , 3 bathrooms, medication closet , laundry area , garage and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and John 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: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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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