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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002763
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:45:23 PM

Document Has Been Signed on 07/24/2023 01:45 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator-Courtney DuganTIME COMPLETED:
01:55 PM
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On 07/24/2023, Licensing Program Analysts (LPA's) Jaynae Boyles and Kerry Hiratsuka, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA's met with Facility Program Manager Courtney Dugan, and explained the purpose of the visit.

LPA's Boyles, Hiratsuka and Program Manager toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, and common restrooms. LPA's observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a two day perishable and a seven day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 120 F. LPA's observed three (3) fire extinguishers which were last services 08/09/2023. LPA's observed working fire detectors and carbon monoxide detectors.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of two (2) residents' files and two (2) staff files.

Several topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by 08/07/2023:

-facility sketch

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

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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