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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004613
Report Date: 12/15/2021
Date Signed: 12/15/2021 09:53:12 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/15/2021 09:53 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:CROWN JEWEL VILLAFACILITY NUMBER:
347004613
ADMINISTRATOR:DASCALESCU, IONELFACILITY TYPE:
740
ADDRESS:5422 YDRA COURTTELEPHONE:
(916) 989-5511
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 0DATE:
12/15/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:LUMINITA DASCALESCUTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 12/15/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Luminita Dascalascu, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA toured the facility to ensure the health and safety of the facility. Areas toured include but are not limited to: 5 bedrooms and 3 bathrooms for residents, common area, dining room, kitchen, laundry room, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Luminita discussed the infection control domain which the licensee is successfully implementing in their other facility.

LPA reminded licensee of today's Informational call.


No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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