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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002628
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:22:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/24/2022 02:22 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:MOUNTAIN MEADOW LODGEFACILITY NUMBER:
045002628
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:585 BILLE RDTELEPHONE:
(530) 872-9002
CITY:PARADISESTATE: CAZIP CODE:
95969
CAPACITY:17CENSUS: 0DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Cliff KeeneTIME COMPLETED:
01:00 PM
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On 2/24/22 at 11:00 AM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a Required -1 Year Inspection utilizing the infection control domain. LPA met with licensee Cliff Keene at Inn At The Terraces (2950 SIERRA SUNRISE TERRACE Chico CA 95928) 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.

This facility was destroyed as a result of the 2018 Camp Fire and there are no residents in care. The licensee wishes to maintain the license in the event the facility is rebuilt.

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

Exit interview conducted and copy of report will be emailed to administrator/licensee Cliff Keene.
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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