<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001839
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:25:27 PM


Document Has Been Signed on 03/16/2022 04:25 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:IRIS CARE HOMEFACILITY NUMBER:
045001839
ADMINISTRATOR:ANGHELUTA, NICOLETAFACILITY TYPE:
740
ADDRESS:4117 LOWER WYANDOTTE RD.TELEPHONE:
(530) 534-7996
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:8CENSUS: DATE:
03/16/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Rebecca Drummond - care staffTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
03/16/2022 4:30 PM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with care staff Rebecca Drummond. The purpose of this visit was to deliver eight (8) resident files that were picked up at the facility for copying on 3/11/2022.

Prior to initiating the visit, 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 ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

LPA Knight handed Ms. Drummond the resident files. Licensee signature is proof of delivery.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1