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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002500
Report Date: 02/08/2023
Date Signed: 02/08/2023 02:35:45 PM

Document Has Been Signed on 02/08/2023 02:35 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,
, CA
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: 2DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Carrie Segee - House ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met with House Manager and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA Wallace and house manager toured facility together to ensure health and safety of clients who attend the day program. Areas toured include but are not limited to: common areas, bathrooms, office, and storage rooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

Hot water temperature was measured at 109.8 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected on 9/19/2022. Smoke and carbon monoxide sensors are in compliance with fire safety. Thermostat observed at (73.6) degrees Fahrenheit. LPA reviewed two (2) client records and three (3) staff records. All documents were complete and staff have current first aid certificates.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report was provided to house manager at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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