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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700877
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:40:37 PM

Document Has Been Signed on 10/20/2022 04:40 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:ROBERT CREEK VILLA IFACILITY NUMBER:
342700877
ADMINISTRATOR:SBINGU, ADINAFACILITY TYPE:
740
ADDRESS:8135 ROBERT CREEK VILLA COURTTELEPHONE:
(916) 745-4230
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 6DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Maria Radu, caregiver, and Florica Sferdian, Co-AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Maria Radu, caregiver and explained purpose of inspection. LPA met with Florica Sferdian, Co-Administrator who arrived at 3:30 pm. . LPA observed (6) residents to be in their rooms at the start of the inspection. Currently, there is (1) resident on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Prior to initiating today's inspection, LPA completed required COVID-19 protocols. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA, caregiver Co-Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms with private bath, (2) full bathrooms, kitchen, staff rooms and garage/locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters posted. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and toxins in the kitchen and medications to be secured nearby. LPA observed the inside temperature to be 78*F. Fire extinguisher was last serviced 6/30/2022 and facility conducts quarterly fire drills. Discussed vaccination status of residents/staff, eligibility for boosters and updated visitation protocols. Booster flyers provided. LPA observed multiple Covid posters posted throughout as well as other required postings. LPA observed copy of approved Mitigation Plan, Infection control plan and Monkey Pox plan. LPA observed (1) unlocked gate from the inside back patio with covered patio seating. There are no pools or bodies of water. LPA observed copy of RCFE Administrator certificate # 6004705740- exp 11/2/23. LPA observed closet full of PPE.

LPA requested an updated copy of LIC500, LIC308 and current liability insurance today by 10/27/22.
There are no deficiencies issued during today's inspection.
Exit interview with Administrator. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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