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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002766
Report Date: 10/30/2022
Date Signed: 10/30/2022 02:26:48 PM

Document Has Been Signed on 10/30/2022 02:26 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:CASA DE AMORFACILITY NUMBER:
045002766
ADMINISTRATOR:SERRANO, NORAFACILITY TYPE:
735
ADDRESS:162 HAMMON PARKTELEPHONE:
(530) 403-9510
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 4CENSUS: 3DATE:
10/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Erica Ocampos (Flores)TIME COMPLETED:
03:00 PM
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On 10/30/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required 1-yr Annual inspection. LPA met with direct care support, Erica Ocampos (Flores), and explained the purpose of the visit. Prior to the visit, 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Facility's capacity is 6, LPA observed (3) clients present at the facility.

LPA and staff toured the interior of the facility to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and staff followed the infection control domain guidelines and facility was found to be in compliance at this time. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishable food. LPA observed the Administrator Certificate #6009563735 to be up to date with the expiration date of 12/22/2023.

During this visit, LPA obtained a copy of the LIC 402.

LPA further requested a copy of Administrator Certificate, LIC 308, LIC 500, and LIC 808 to be submitted to LPA via fax or e-mail by Friday November 4, 2022.

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: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2022
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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