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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005161
Report Date: 10/18/2022
Date Signed: 10/18/2022 03:11:31 PM

Document Has Been Signed on 10/18/2022 03:11 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
CHICO - RESIDENTIAL, 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: DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cecilia SuaybaguioTIME COMPLETED:
03:30 PM
NARRATIVE
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On 10/18/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff who LPA asked to contact Administrator to be present at the facility. 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 and contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. LPA was not screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. LPA observed (6) residents to be present at the facility, and (0) residents to be on hospice services. LPA advised Administrator to screen all visitors for symptoms of COVID-19 upon entry. LPA advised facility to have hand washing posters in the bathrooms. LPA observed Administrator Certificate to be up to date. LPA observed the fire extinguisher to be last serviced 11/2/2020. LPA informed Administrator that it needs to be serviced every 12 months. LPA observed (3) individuals in the facility without a mask. LPA informed Administrator that staff and visitors are mandated to wear mask while residents are in care.

At this time, LPA obtained copies of Administrator Certificate, LIC 500 and current liability insurance. LPA requested a copy of LIC 308 (Designation of Responsibility) to be emailed to LPA by 10/25/2022.

As a result of today's inspection, deficiencies were observed and cited. Please see attached LIC 809-D and LIC 9102.

Exit interview conducted and copy of report and appeal rights left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2022
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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Document Has Been Signed on 10/18/2022 03:11 PM - It Cannot Be Edited


Created By: Cassie Yang On 10/18/2022 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A & C CARE HOME #2
FACILITY NUMBER: 347005161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation, the licensee did not comply with the section cited above in as LPA observed 3 out of 5 staff and/or visitors inside the facility to not be masked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2022
Plan of Correction
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Staff and visitors are to wear mask while residents are in care. All staff and visitors were asked to immediately put on a mask.
Licensee is to submit a statement of compliance to CCLD via email or fax by Tuesday October 25, 2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022


LIC809 (FAS) - (06/04)
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