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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002763
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:04:30 AM

Document Has Been Signed on 08/03/2022 11:04 AM - 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:MAINS'L - MONTEREYFACILITY NUMBER:
045002763
ADMINISTRATOR:FORGE, VIOLAFACILITY TYPE:
735
ADDRESS:278 PANAMA AVETELEPHONE:
(530) 899-1907
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 5CENSUS: 2DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Dariana Hernandez
Brandi Wilson 		TIME COMPLETED:
11:30 AM
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08/03/2022 at 8:40 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 care staff Dariana Hernandez and administrative staff Brandena Wilson 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

LPA Avila the toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, and kitchen. LPA Avila completed the infection control domain and Provided technical assistance to the facility.

LPA requested the following documents by COB on 8/4/2022:
-Change of Administrator documentation
-LIC 808 and LIC 9282 ref PIN 22-18 ASC
-LIC 500
-Lease agreement for property

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report given to Administrator.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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