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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005716
Report Date: 03/24/2022
Date Signed: 03/24/2022 11:29:34 AM

Document Has Been Signed on 03/24/2022 11:29 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:FOUNTAINS SENIOR CARE SECOND LLC, THEFACILITY NUMBER:
317005716
ADMINISTRATOR:MACIUCA, ESTERAFACILITY TYPE:
740
ADDRESS:5422 CASA GRANDE AVENUETELEPHONE:
(916) 470-1416
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 5DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator(acting)- Claudia MartinezTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced on 03/24/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA and LPM met with, Administrator(acting)- Claudia Martinez , and explained the purpose of the visit. Prior to initiating the annual inspection, LPA and LPM completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA and LPM wore the following Personal Protective Equipment (PPE) during today's visit: surgical masks. LPA and LPM were screened by facility staff before entry to facility.

LPA, LPM and Claudia toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, five (5) bedrooms, two (2) bathrooms, medication closet, garage, laundry room and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

During the facility walk thru, LPA and LPM observed an uncleared staff room connected to the garage. This room is not located on the facility sketch nor did the licensee notify CCL of the room conversion. A fire clearance will need to be requested and conducted to clear this room for staff use.

LPA and Claudia completed the infection control domain together and facility was found to be in substantial compliance at this time.

Deficiencies are being cited today per California Code of Regulations, Title 22 due to the uncleared staff room.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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Document Has Been Signed on 03/24/2022 11:29 AM - It Cannot Be Edited


Created By: Talwinder Bains On 03/24/2022 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: FOUNTAINS SENIOR CARE SECOND LLC, THE
FACILITY NUMBER: 317005716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(b)
87305 Alterations to Existing Building or New Facilities
(b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The Licensee converted a staff bedroom connected the garage and did not notify CCL or update facility sketch. Permits were obtained however a fire clearance has not been complete, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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The Licensee shall submit an updated facility sketch which includes the staff room connected to the garage. In addition, the licensee shall submit approved permits from Rocklin City Building Department. Lastly, the licensee shall submit a letter to CCL indicating the room connected to the garage will be for staff use only. POC shall be submitted by 04/21/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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