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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001756
Report Date: 04/13/2022
Date Signed: 04/13/2022 11:36:04 AM


Document Has Been Signed on 04/13/2022 11:36 AM - 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:COMPASS ROSEFACILITY NUMBER:
045001756
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2750 SIERRA SUNRISE TERRACETELEPHONE:
(530) 774-2705
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:48CENSUS: 29DATE:
04/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cliff Keene and Pomoli ThitphanethTIME COMPLETED:
12:00 PM
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On 4/13/2022 at about 9:45 AM Licensing Program Analysts (LPA) Jaclyn Avila and David Loperena arrived at the facility unannounced to conduct and unannounced case management visit on to Unusual incident reports that came in. LPAs met with administrator Cliff Keene and RSD Pomoli Thitphaneth and explained the purpose of the visit. Prior to initiating the visit, LPAs 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 ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. Additionally, LPA Avila and Loperena was screened by care staff upon entrance to the facility.

LPAs discussed two self-reported incident reports that were sent in to the Chico CCLD office as required by regulation. LPAs reviewed staff schedules, LIC 602s, and care plans for 2 residents. Both residents had taken falls that resulted in injuries. Both falls were isolated incidents and facility ensured residents medical needs were met.

LPAs discussed implementing an ADL checkoff sheet for staff to establish time frames and accountability

No citations were issued. Per Administrators request report will be e-mailed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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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