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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002620
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:36:57 PM


Document Has Been Signed on 12/29/2022 12:36 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
CHICO - RESIDENTIAL, 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: 84DATE:
12/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cliff Keene- Executive Director TIME COMPLETED:
12:45 PM
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On December 29, 2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management visit. LPA met with Executive Director, Cliff Keene, and explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff prior to entering the facility.

The purpose of the visit was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 12/07/2022. The report indicated resident (R1) lost her balance and had a fall witnessed by staff. R1 complained out left hip pain. R1 was transferred to hospital for evaluation. R1's responsible party were notified by the facility. R1 was diagnosed with fall, contusion of food, head injury, and contusion of hip. R1 returned to the community the same day with no new orders. R1 placed on alert charting 48 hours to monitor.

LPA requested for R1's Physician's Report, Reappraisal, Level of Care Assessment, and medical discharge documents, and fall prevention training. R1 returned to the community and is doing well.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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