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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001341
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:57:15 PM

Document Has Been Signed on 11/08/2021 01:57 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:GRIDLEY ADULT SERVICES PROGRAMFACILITY NUMBER:
045001341
ADMINISTRATOR:VARGAS, TERESAFACILITY TYPE:
775
ADDRESS:262 LITTLE AVENUETELEPHONE:
(530) 846-4988
CITY:GRIDLEYSTATE: CAZIP CODE:
95948
CAPACITY: 25CENSUS: 17DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Teresa VargasTIME COMPLETED:
02:24 PM
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11/08/2021 1:10 PM Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain .LPA met with Administrator (AD) Teresa Vargas 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 AD 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: N95. Additionally, LPA Keane was screened by AD.

LPA's Keane and AD toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) bathrooms, isolation room, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the AD completed the infection control domain and facility was found to be in substantial compliance at this time.
No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report was given to AD.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Dawn Keane
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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