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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 08/09/2023
Date Signed: 08/09/2023 12:40:19 PM

Document Has Been Signed on 08/09/2023 12:40 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: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: 6DATE:
08/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Blanca Chavez- house managerTIME COMPLETED:
12:45 PM
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08/09/2023 11:10 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with house manager Blanca Chavez,and explained the purpose of the visit. Administrator Nora Serrano 6009563735 exp. 12/22/2023 was unavailable at the time of the visit.

LPA Knight and Ms. Chavez toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) bathrooms, kitchen, storage areas and yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current.

Recreational activities are pre-planned each week. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in December 2022. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in December 2023 which was a fire drill and the facility is due to perform an emergency drill.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Technical assistance was provided.

Exit interview conducted and copy of report was provided to administrator Nora Serrano.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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