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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700142
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:33:09 PM

Document Has Been Signed on 06/23/2021 03:33 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:LOVE YOU MOMFACILITY NUMBER:
342700142
ADMINISTRATOR:GERGI, EDUARDFACILITY TYPE:
740
ADDRESS:6809 MELLODORA DRIVETELEPHONE:
(916) 807-4319
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 4DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Agafia Gergi, designated administratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 06/23/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with staff, LaToya King (S1) and 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 and contacted licensee 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 Mask. Additionally, LPA was screened by S1 upon entry.

S1 contacted administrator Eduard Gergi and informed him of LPAs presence, Eduard was unable to meet LPA for inspection but designated administrator, Agafia Gergi arrived shortly after LPA's arrival to complete inspection.

LPA, S1, and designated administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, brief inspection of three (3) resident bedrooms, resident bathrooms, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and designated administrator 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 todays inspection.
Exit interview conducted and copy of report to be emailed to administrator.

Administrator to send the department current copies of LIC 308 - Designation of Administrative Responsibility, LIC 500 - Personnel Report, LIC 610E - Emergency Disaster Plan, and current liability insurance by 07/02/2021.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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