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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002776
Report Date: 01/05/2022
Date Signed: 01/05/2022 02:26:04 PM

Document Has Been Signed on 01/05/2022 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
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: 11DATE:
01/05/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Todd Harris TIME COMPLETED:
02:40 PM
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01/05/2022 at 1:45 PM, 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 administrator Todd Harris 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: PAPR. Additionally, LPA Avila was screened by facility staff.

LPA Avila and Mr. Harris toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathrooms, kitchen, dining room, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Avila and the administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection

Exit interview conducted and copy of report was emailed to administrator Todd Harris.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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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