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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700960
Report Date: 04/20/2022
Date Signed: 04/20/2022 10:33:00 AM

Document Has Been Signed on 04/20/2022 10:33 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:ECLIPSE HOME CAREFACILITY NUMBER:
342700960
ADMINISTRATOR:SAEGER, MAGDALENAFACILITY TYPE:
740
ADDRESS:9374 MANETTE WAYTELEPHONE:
(916) 904-6551
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 4DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Magdalena, Saeger, AdministratorTIME COMPLETED:
11:00 AM
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On April 20 2022, at 9am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required 1 year inspection. LPA met with Administrator Magdalena Saeger 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 wore a mask for Personal Protective Equipment (PPE). Additionally, LPA was screened by care staff upon arrival.

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

LPA observed the following: Administrators Certificate is valid expiring November 19, 2022. First Aid Kit was complete and ready for emergency use. Fire extinguishers fully charged. Smoke detector and Carbon Monoxide detector are functional. Facilities temperature measured 72 degrees F. Common areas were clean and in good repair. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medication was properly stored and locked away.

To continue see 809-C...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ECLIPSE HOME CARE
FACILITY NUMBER: 342700960
VISIT DATE: 04/20/2022
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Per California Code of Regulations, Title 22, no deficiencies were observed.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D 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 no later than May 20, 2022.

Exit interview with Magdalena was conducted and a copy of this report was left with her.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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