045001436-9-15-2022-25-AS-RWAE-CJASXZ-20220915141646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:16:49 PM

Document Has Been Signed on 09/15/2022 02:16 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,
, CA

FACILITY NAME:	PINE VILLE CARE HOME		FACILITY NUMBER:	045001436
ADMINISTRATOR:	SERRANO,NORA CHAVEZ		FACILITY TYPE:	735
ADDRESS:	1681 PINE STREET		TELEPHONE:	(530) 533-1851
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY: 6		CENSUS: 6	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Blanca Chavez - House Manager		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ruth Wallace arrived at the facility unannounced to conduct a Required -1 Year Inspection Visit utilizing the infection control domain. LPA met with House Manager (HM)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. LPA Wallace ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical masks. Additionally, LPA Wallace was screened by HM.

LPA Wallace and HM 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 HM completed the infection control domain and facility was found to be in substantial compliance at this time. Kitchen area was toured. Food preparation station, dishwashing station, and food storage units were reviewed. Food supply was reviewed for adequate 2 day perishable supply and 7 day nonperishable supplies. Medications were reviewed for one resident and compared with centralized medication record. Surety Bond expires 1/23/2023.
LPA observed the smoke/monoxide alarms to be in working order and the fire extinguishers are charged which expire 12/20/2022. Facility is conducting quarterly fire drills as required, last drill on 6/10/2022 . The hot water measured 114.5*F which is within the required range of 105-120*F.

LPA reviewed 3 of resident records. LPA reviewed 3 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed current first aid certificates and they are current.

No deficiencies cited today according to California Code of regulations, Title 22.

Exit interview conducted with HM. A copy of report were given to HM.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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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