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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005161
Report Date: 07/27/2021
Date Signed: 08/03/2021 02:19:59 PM

Document Has Been Signed on 08/03/2021 02:19 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:A & C CARE HOME #2FACILITY NUMBER:
347005161
ADMINISTRATOR:SUAYBAGUIO, CECILIAFACILITY TYPE:
740
ADDRESS:3601 GARFIELD AVE.TELEPHONE:
(916) 993-8755
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cecilia Suaybaguio (Admin)TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility on 7/27/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Cecilia Suaybaguio (Admin) and explained the purpose of the visit. Prior to initiating the annual 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; contacted admin 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: N-95 Masks. Additionally, LPA was screened by staff and answers were documented in their visitor screening log.

LPA and admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) of six (6) resident bedrooms, three (3) of three (3) bathrooms, kitchen, garage, staff room, and backyard. In the areas toured no immediate violations were observed. LPA and admin completed the infection control domain and facility was found to be in compliance at this time.

No deficiencies are being cited as a result of today’s inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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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