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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002960
Report Date: 01/17/2023
Date Signed: 01/31/2023 01:48:55 PM

Document Has Been Signed on 01/31/2023 01:48 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:JOY'S CARE HOME-ELMFACILITY NUMBER:
315002960
ADMINISTRATOR:SUSBILLA, GLORIA JOYCE BROFACILITY TYPE:
740
ADDRESS:256/258 ELM STREETTELEPHONE:
(916) 297-5675
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
01/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Calvin Bron-SusbillaTIME COMPLETED:
01:15 PM
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On 1/17/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted a pre-licensing inspection with Licensee.
Prior to initiating the annual inspection, LPA completed the Department's required COVID-19 protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility. Administrator is present at the facility to conduct an annual inspection.
LPA toured Physical Plant, Food Service, Common Areas, Bedrooms, Bathrooms, Kitchen and Medication Storage. Fire extinguisher is current and First Aid is fully stocked. Kitchen was clean and good repair. Licensee has knowledge of (7) seven (2) two day supply of non-perishable and perishable, and required emergency shelter in place supplies. Rooms inspected have appropriate items and are in good repair. LPA observed centrally stored medications and toxins are to be kept locked and inaccessible to residents. Staff and resident files are to be set up to contain required documents (see next paragraph). Covid 19 guidelines and signage are adhered to.
LPA issued an advisory for R1's medication records to be updated- Physician's orders for all medications and a PRN authorization form to be completed/ updated prior to licensure.
Facility will accept total capacity of six elderly residents. LPA observed this facility appears to be clean, safe, and secured. All common areas appear to be free from hazards, clean and in good repair. As of this date, the Department has received the fire clearance. During this visit, this facility is in substantial compliance and meets the minimum requirements for a RCFE license.
Prior to license issue, licensee will correct R1's medication records.
Component III was waived.
Application is pending further review.

Report reviewed and copied to licensee

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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