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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002120
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:01:48 AM

Document Has Been Signed on 02/09/2023 11:01 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:TRES MARIAS CARE HOME IFACILITY NUMBER:
045002120
ADMINISTRATOR:DEVILLA, MARIAFACILITY TYPE:
735
ADDRESS:2153 4TH STREETTELEPHONE:
(530) 532-7508
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Devilla, AdministratorTIME COMPLETED:
11:00 AM
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02/08/2023 10:20 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Maria Devilla, Administrator 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 ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask, gloves.

LPA Knight and Ms Devilla toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to:four (4) client rooms, common areas, two (2) bathrooms, dining room, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight, and Ms.Devilla 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. Technical assistance was provided.

Exit interview conducted and copy of report was provided to Maria Devilla, Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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