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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002776
Report Date: 12/07/2023
Date Signed: 12/07/2023 10:48:41 AM

Document Has Been Signed on 12/07/2023 10:48 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TRINITY PINESFACILITY NUMBER:
045002776
ADMINISTRATOR:CRYSTAL TORRESFACILITY TYPE:
772
ADDRESS:2753 WHITE AVENUETELEPHONE:
(530) 751-9900
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 16CENSUS: 16DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator- Crystal Torres TIME COMPLETED:
11:00 AM
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On 12/7/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator,Crystal Torres and explained the purpose of the visit.

LPA Boyles and Administrator 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, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, and trash can with lids.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 108 F. LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors all of which were serviced in October of 2023.

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

LPA reviewed a total of five (5) residents' files and four (4) staff files which contained all the required documentation.

Several topics were discussed.

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: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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