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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700795
Report Date: 12/09/2021
Date Signed: 12/09/2021 09:20:10 AM

Document Has Been Signed on 12/09/2021 09:20 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:EMF FLORES CARE HOME #2FACILITY NUMBER:
342700795
ADMINISTRATOR:FLORES, ELOISAFACILITY TYPE:
740
ADDRESS:8500 PALLADAY ROADTELEPHONE:
(916) 991-3494
CITY:ELVERTASTATE: CAZIP CODE:
95626
CAPACITY: 6CENSUS: 5DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Eloisa Flores, LicenseeTIME COMPLETED:
09:42 AM
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On December 8, 2021, at 8:30am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with Eloisa Flores Executive Director and explained purpose of inspection. Prior to initiating the 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 completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Additionally, LPA was screened by Eloisa upon arrival.

Eloisa and LPA completed the inspection tool questionnaire with no issues or advisories to report.

LPA observed the following:
Administrator certificate is valid 5/13/2023. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Common areas were clean and in good repair. Facility has the required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.
The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than January 9, 2022.

Exit interview conducted and a copy of this report given to Eloisa.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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