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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002620
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:18:55 PM


Document Has Been Signed on 02/24/2022 02:18 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:INN AT THE TERRACES, THEFACILITY NUMBER:
045002620
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2950 SIERRA SUNRISE TERRACETELEPHONE:
(530) 894-5429
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:99CENSUS: 86DATE:
02/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cliff KeeneTIME COMPLETED:
01:30 PM
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On 2/24/2022 at 1:00PM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a case management on two incident reports received related to falls, LPA met with Executive Director/Administrator Cliff Keene 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; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask

LPA reviewed an incident report that detailed an incident that occurred on 1/8/2022. On this date a resident (R1) fell out of bed resulting in the need for medical attention. LPA discussed the residents diagnosis with Administrator. ONR (occupational therapy) assessed him for a change in condition. R1 has not had a fall since.

LPA reviewed an incident report that detailed an incident that occurred on 1/10/2022. On this date a resident (R2) tripped on her own feet, falling and resulting in complaints of pain to shoulder and head. R2 refused to be transported by EMS. LPA discussed the incident with Administrator who stated the occupational therapist assessed R2 for change in condition and assessed R2 for fall risk. Administrator said since the incident R2 has not had another fall and is still receiving physical therapy.

No deficiencies cited.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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