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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001444
Report Date: 08/19/2021
Date Signed: 08/19/2021 09:42:30 AM

Document Has Been Signed on 08/19/2021 09:42 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:HIDDEN LAKE CARE HOMEFACILITY NUMBER:
315001444
ADMINISTRATOR:COPACIU, LYDIAFACILITY TYPE:
740
ADDRESS:8405 ACORN DRIVETELEPHONE:
(916) 791-2596
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 6CENSUS: 4DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lydia Copaciu (Admin)TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility on 08/19/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Lydia Copaciu (Admin) and Eugene Copaciu (Staff) 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 admin 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 Lydia and answers were documented in their visitor screening log.

LPA, admin and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) of three (3) resident bedrooms, two (2) of two (2) bathrooms, kitchen, garage, backyard and storage shed. 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.

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: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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