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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002850
Report Date: 11/16/2021
Date Signed: 11/16/2021 01:38:30 PM

Document Has Been Signed on 11/16/2021 01:38 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:ECLIPSE HOME CARE IIFACILITY NUMBER:
345002850
ADMINISTRATOR:SAEGER, MAGDALENAFACILITY TYPE:
740
ADDRESS:137 YANKTON ST.TELEPHONE:
(916) 985-8851
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 6CENSUS: 6DATE:
11/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Licensee Magdalena Saeger and Administrator Gabriel Bercea TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 11/16/2021 to conduct a Prelicensing inspection. LPA met with Licensee and Administrator, Magdalena Saeger and Garbriel Bercea, and explained the purpose of the visit. Prior to initiating the Prelicensing 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 contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA was allowed entry into the facility that will be licensed for a capacity of six (6). LPA toured the interior and exterior of the facility with Licensee and Administrator. The indoor and outdoor passageways were free of obstruction. Upon entering the facility LPA observed COVID-19 signages.

Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, kitchen, garage, medication room, and backyard. LPA observed knives/sharps were locked in the kitchen by sink. LPA observed the require furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. Hot water temperature was measured in residents' bathroom at 102 degrees Fahrenheit. First aid kit was completed with bandages, tweezers, scissors, and thermometer located in the medication room.

LPA observed one (1) fire extinguisher in the kitchen. Licensee and Administrator stated the facility has a fire sprinkler system set up at the facility as well. LPA observed fire detectors and carbon monoxide.

Component III presentation conducted with Licensee and Administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with Licensee and this report will be provided to the facility via email.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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