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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005412
Report Date: 05/25/2022
Date Signed: 05/25/2022 09:56:02 AM

Document Has Been Signed on 05/25/2022 09:56 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:VIRGINIA DENISE COUNTRY HOMEFACILITY NUMBER:
347005412
ADMINISTRATOR:FERMO, AILEENFACILITY TYPE:
740
ADDRESS:2305 VIRGINIA DENISE LANETELEPHONE:
(916) 813-0460
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 4DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Aileen Fermo, LicenseeTIME COMPLETED:
10:09 AM
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On May 25, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an annual inspection. LPA met with Aileen Fermo, Licensee, and advised her the reason for the visit.

Prior to the visit, 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 licensee 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.

LPA and Aileen completed the Infectious Control questionnaire with no issues or advisories. LPA and Aileen toured the home. There are no bodies of water on the premises. The smoke alarm was working. The Medication Administration Record was viewed and found to be completed.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 108 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility.
Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be enough and in good repair. Resident bedrooms and bathrooms were toured.

To continue see 809-C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
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: VIRGINIA DENISE COUNTRY HOME
FACILITY NUMBER: 347005412
VISIT DATE: 05/25/2022
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Bedrooms had all the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer were present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible.

First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current.

Staff records reviewed indicated current First Aid & CPR certificates. Facility is conducting staff training as required.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than June 25, 2022.

An exit interview was conducted, and a copy of this report was given to Aileen

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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