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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003304
Report Date: 09/16/2022
Date Signed: 09/16/2022 02:34:11 PM

Document Has Been Signed on 09/16/2022 02:34 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:HOMEVILLE CAREFACILITY NUMBER:
347003304
ADMINISTRATOR:VIERU, GABRIELAFACILITY TYPE:
740
ADDRESS:6536 NORDIC COURTTELEPHONE:
(916) 532-0061
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 6DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gabriela Vieru, Administrator TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Pamella Pusey, caregiver and explained purpose of inspection. LPA met with Administrator, Gabriela Vieru, who arrived at 11:30 am. LPA observed (3) residents in the common area watching television and (3) residents to be in their rooms at the start of the inspection. Currently, there are (2) residents on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (6). Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and toured the Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (4), resident bathrooms (2.5), kitchen, staff room and 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 in the kitchen and observed toxins and medications to be secured nearby. LPA observed the inside temperature to be 76*F. Fire extinguisher was last serviced 2/16/2022 and facility conducts monthly fire drills. Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols and observed binders with verification of visitor, staff and resident vaccination status. Booster flyers provided. Administrator indicated there will be an on-site booster clinic later this month. LPA reviewed (1) resident binder (2) staff binders and observed them to be complete, organized and contain current documentation LPA observed multiple binders containing Mitigation Plan and other Infection Control Plans. LPA observed multiple Covid posters throughout as well as other required postings, including several Provider Information Notice (PIN) from the Department. Administrator provided documentation, dated June 2022, showing fire approval to create an isolation room using part of garage space- expected to be completed by Dec 2022. . Cont 809C..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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: HOMEVILLE CARE
FACILITY NUMBER: 347003304
VISIT DATE: 09/16/2022
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809C.. All staff is fingerprint cleared and associated and has current First Aid/CPR and other required training. LPA observed (1) unlocked gate from the inside back patio. There are no bodies of water or a pool. There is also a front enclosed patio area where residents can have visitors.

LPA observed sufficient incontinent products and PPE on hand. LPA provided PPE supplies of (1) package of gowns and (6) individual bottles of sanitizer from the Department today.

LPA observed Administrator certificate #6007196740- exp 9/18/2023 to be posted. Administrator to post visitor hours by front entrance.

LPA obtained an updated copy of LIC500, LIC308 and current liability insurance today.

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: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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