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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700340
Report Date: 12/17/2021
Date Signed: 12/20/2021 11:57:37 AM

Document Has Been Signed on 12/20/2021 11:57 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:LEXINGTON HILLS SENIOR CARE LLCFACILITY NUMBER:
342700340
ADMINISTRATOR:DAVIDSON, MICHELLEFACILITY TYPE:
740
ADDRESS:164 BISCAYNE WAYTELEPHONE:
(916) 225-5204
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 6CENSUS: 6DATE:
12/17/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Romelia HorjaTIME COMPLETED:
04:30 PM
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On 12/17/2021 LPA Tryon visited the facility to perform an Annual Inspection using the Infection Control Domain of the Annual Tool. LPA met with licensee/administrator Romelia Horja.

Prior to visiting, LPA had contacted the facility and did a quick screen to learn that there are no COVID positive residents or staff at this time. LPA screened prior to entering including taking temperature and using hand sanitizer.
LPA requested a copy of most recent Administrator Certificate, copy of liability insurance, and current staff schedule.

LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, storage. Food supplies and other supplies appear to be in adequate supply and of good quality.

A Technical Advisory was issued regarding N-95 Fit Testing. The facility is in the process of finding a resource.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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