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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002776
Report Date: 08/17/2021
Date Signed: 08/17/2021 11:29:57 AM

Document Has Been Signed on 08/17/2021 11:29 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:TRINITY PINESFACILITY NUMBER:
045002776
ADMINISTRATOR:HARRIS, TODDFACILITY TYPE:
772
ADDRESS:2753 WHITE AVENUETELEPHONE:
(530) 751-9900
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 12CENSUS: DATE:
08/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TODD HARRISTIME COMPLETED:
11:40 AM
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Donna Gurriere, Licensing Program Analysts (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by administrator/staff person upon entering the facility.

On 07/29/21 it was reported that there was a medication error for a resident (Resident 1) on 06/19/21. It was reported that the resident only received one tablet, rather than the prescribed two tablets of the medication. It was reported that there was not an adverse reaction observed and the physician was contacted..

The facility reported that training was provided to the staff person to decrease the likelihood of a similar incident occurring in the future.

An exit interview was conducted and a copy of the report was given to the administrator. No deficiencies cited.

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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