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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920021
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:08:06 PM

Document Has Been Signed on 10/24/2024 03:08 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CHERRY RIDGE VILLAFACILITY NUMBER:
315920021
ADMINISTRATOR/
DIRECTOR:
KAUR, NIRMALJEETFACILITY TYPE:
740
ADDRESS:6893 CHERRY RIDGE CIR.TELEPHONE:
(916) 786-0654
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/24/24 to conduct a Plan of Correction (POC) visit for inspection conducted 9/25/24. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.LPA spoke by phone with Administrator, Baljeet Singh and house manager, Jerson Quezon.

LPA reiterated that if Licensee wishes to designate Baljeet to be Administrator they are to contact CCL to update facility records. Additionally R4 has an exception approved for the prior licensee. If the exception is still needed, a new exception request must be requested.

LPA conducted a visual tour of the interior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom and kitchen. In the areas toured health, safety deficiencies were observed. Residents appeared to have their care needs met. Citations previously cited are corrected.

LPA reviewed resident and staff files and verified citations previously cited are corrected.

During today's visit, LPA observed a new caregiver, S2,who has fingerprint clearance but is not associated. Licensee to due a transfer request. S2 has yet to complete their initial 20 hours of training. LPA discussed with staff that that is to be completed before independently working with residents. LPA also discussed with S1 that their personal medication needs to be in a locked area if not kept on their person.


As a result of this visit, no deficiencies are being cited at this time.

Exit interview conducted with caregiver and copy of report is to be emailed to licensee.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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