<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004852
Report Date: 06/02/2021
Date Signed: 06/02/2021 11:03:24 AM

Document Has Been Signed on 06/02/2021 11:03 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNRIVER SENIOR CARE, LLC.FACILITY NUMBER:
347004852
ADMINISTRATOR:DIZON, SUSIEFACILITY TYPE:
740
ADDRESS:11229 PECOS RIVER COURTTELEPHONE:
(916) 853-1925
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 6CENSUS: 5DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shirley DizonTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/2/21 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Sunriver Senior Care, LLC for the purpose of conducting a required 1 year annual inspection. LPA met with licensee Shirley Dizon and together conducted a tour of the facility and discussed the facility COVID mitigation plan. Current census is 5.

The facility is a split level home with resident bedrooms on the ground floor, kitchen and staff offices on the split level and the upstairs consists of three bedrooms occupied by the licensees adult son and child. LPA inspected the facility with Shirley including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room, and backyard. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. There are no bodies of water present in the facility at this time. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers, smoke detectors, and carbon monoxide detectors were observed in the facility and current. First aid kit was checked and is complete.

LPA observed centrally stored medications stored inaccessible to residents. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility.

There are no deficiencies cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the licensee and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1