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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700675
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:08:09 PM

Document Has Been Signed on 11/08/2021 02:08 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CALI CARE RETIREMENT HOME IIFACILITY NUMBER:
342700675
ADMINISTRATOR:MOJICA, EMMANUELFACILITY TYPE:
740
ADDRESS:5125 CHICAGO AVETELEPHONE:
(916) 534-7477
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 5DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Regina Mata, CaregiverTIME COMPLETED:
02:20 PM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the facility unannounced on 11/8/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with caregiver and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPAs were screened by staff upon entry and signed visitor log with temperatures.

LPA Angela Hood spoke to the Administrator, Monica Mojica, by phone and Monica stated that caregiver can sign report.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 5 bedrooms and 3 bathrooms for residents, common area, dining room, kitchen, outdoor area, and viewed PPE supplies. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in compliance at this time.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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