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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005412
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:42:11 PM

Document Has Been Signed on 06/19/2024 12:42 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VIRGINIA DENISE COUNTRY HOMEFACILITY NUMBER:
347005412
ADMINISTRATOR/
DIRECTOR:		FERMO, AILEENFACILITY TYPE:
740
ADDRESS:2305 VIRGINIA DENISE LANETELEPHONE:
(916) 813-0460
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 4DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Aileen Fermo, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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 June 19, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a yearly annual inspection. LPA met with Aileen Fermo, Licensee and informed her the reason for the visit. The Administrators Certificate expired in October 2025.

Aileen and LPA completed the Infectious Control questionnaire with no issues or concerns. LPA was unable to interview staff and clients due to them not at home.

This is a 4 bedroom home. All rooms had the required items of furniture such as bed, dresser, and closet. The restrooms were clean and consisted of grab bars and non skid mats. All toilets, tubs and showers were in good working order. The facility has a working washer and dryer plus enough linen for the residents. 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. There’s appropriate lighting throughout the facility. 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. The facility's temperature was 74 degrees F. Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be enough and in good repair.

To continue see 809-C..
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VIRGINIA DENISE COUNTRY HOME
FACILITY NUMBER: 347005412
VISIT DATE: 06/19/2024
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
26
27
28
29
30
31
32
First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. This facility sits on 2 acres and the backyard is landscaped.

There’s a centralized storage area for resident’s medication. Medication cabinet was locked. Staff records reviewed indicated current First Aid & CPR certificates. Facility is conducting staff training as required. LPA reviewed 2 client files. Files had the the proper updated documents in them.

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 July 19, 2024.*******

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

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2