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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 09/09/2021
Date Signed: 10/08/2021 12:50:06 PM

Document Has Been Signed on 10/08/2021 12:50 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:PINE VILLE CARE HOMEFACILITY NUMBER:
045001436
ADMINISTRATOR:SERRANO,NORA CHAVEZFACILITY TYPE:
735
ADDRESS:1681 PINE STREETTELEPHONE:
(530) 533-1851
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: 4DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Annette FrazierTIME COMPLETED:
12:45 PM
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9/09/2021 10:15 AM Licensing Program Analyst (LPA’s) Dawn Keane and Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with adninistrator Annette Frazier 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 administrator and completed a facility risk assessment. LPA Keane ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA's Keane and Valencia was screened by administrator Annette Frazier

LPA Keane, Valencia and Annette toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, three (3) bathrooms, kitchen, storage areas front yard and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Annette 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 administrator Annette.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Dawn Keane
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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