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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002500
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:48:40 PM

Document Has Been Signed on 12/09/2021 02:48 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:CABALLO HOUSEFACILITY NUMBER:
045002500
ADMINISTRATOR:WILSON, BRANDENAFACILITY TYPE:
735
ADDRESS:4229 CABALLO WAYTELEPHONE:
(530) 342-2329
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 6CENSUS: 3DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sandra Avila - care staffTIME COMPLETED:
03:00 PM
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12/09/2021 2:00 PM 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 care staff Sandra Avila and explained the purpose of the visit. Administrator gave permission by telephone for Ms. Avila to conduct the inspection with LPA Knight. 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. Additionally, LPA Knight was screened by facility staff.

LPA Knight and Ms. Avila toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas,resident bedrooms, bathrooms, kitchen, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and Ms. Avila 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 given to Ms. Avila.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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