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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700338
Report Date: 11/24/2021
Date Signed: 11/24/2021 10:31:42 AM

Document Has Been Signed on 11/24/2021 10:31 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:SIGNATURE LIVING ON STORY RIDGE WAYFACILITY NUMBER:
342700338
ADMINISTRATOR:RIMANDO, NORAFACILITY TYPE:
740
ADDRESS:8400 STORY RIDGE WAYTELEPHONE:
(916) 300-5363
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 6DATE:
11/24/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nerry Rimando-Afable, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Nerry Rimando-Afable, to conduct a Plan of Correction (POC) visit. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the care home.

Prior to visit, LPA obtained a copy of the Statement of Understanding regarding 87307(a) Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. Statement states that "staff will no longer be allowed to sleep inside the garage and all personal belongings will be removed immediately. The garage will solely be used as storage, as it was intended."

LPA observed garage and found that all staff belongings have been removed.

POC was cleared during visit. No additional deficiencies were issued during visit.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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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