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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002891
Report Date: 07/08/2022
Date Signed: 07/08/2022 03:16:09 PM


Document Has Been Signed on 07/08/2022 03:16 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:FOOTHILL COTTAGEFACILITY NUMBER:
045002891
ADMINISTRATOR:ABEJO, KRISTINEFACILITY TYPE:
740
ADDRESS:3064 CEANOTHUS AVENUETELEPHONE:
(530) 809-0418
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:6CENSUS: 5DATE:
07/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Kristine AbejoTIME COMPLETED:
03:35 PM
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Licensing Program Analyst(LPA) Jaclyn Avila conducted an announced pre-licensing visit with licensee Kristine Abejo.

This facility has a fire clearance for six non-ambulatory a hospice waiver for two hospice residents. The facility has four resident rooms three of which can hold up to two residents. One room is currently being used as a staff room for live in staff. There is a master bedroom with bathroom and a hallway community bathroom. The kitchen, dining, and common areas were toured. There are locked cabinets for files and medications. The kitchen has a locked cabinet for sharp knives, and cleaning supplies under the sink. There is an exit to the backyard from the dining area. The backyard has a covered patio and sitting area. The passageways on the perimeter of the facility are free of obstructions. This facility is also a vendor with the Far Northern Regional Center.

LPA reviewed component III orientation with the administrator who has prior working experience operating RCFEs.

This facility meets all regulations. LPA will submit this report to the application specialist for final review.

Pre-Licensing is complete and this facility has no deficiencies.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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