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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920157
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:03:24 PM

Document Has Been Signed on 09/24/2024 01:03 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIERRA HEALTH AND WELLNESS-BANGORFACILITY NUMBER:
045920157
ADMINISTRATOR/
DIRECTOR:		PHAM, LORNAFACILITY TYPE:
772
ADDRESS:107 COYOTE MOON TRAILTELEPHONE:
(530) 712-7482
CITY:BANGORSTATE: CAZIP CODE:
95914
CAPACITY: 6CENSUS: 0DATE:
09/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Loran Pham - administratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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09/24/2024 09:35 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with administrator Lorna Pham, Greg Gisla Chief Clinical Officer, Ixel Morell COO, Darryck Dwelle Program Director, Vaness Potier Watts Regional Director of Operations, Emily Henderson Executive Assistant, Tim Jones CNO, and Ryan Hofman Maintenance Specialist Lead and explained the purpose of the visit.

LPA presented Comp 3 during the visit.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. The facility has received fire clearance for six (6) ambulatory clients. The facility has three (3) bedrooms and two (2) bathrooms which are in good condition and ready for use. The bedrooms will be double occupancy. There is one (1) additional bedroom that is located in the garage, the facility does not have for clearance to use this room for clients and no clients are permitted to occupy this room. Per Oroville Fire Department clearance does not include use of garage, applicant has narrowed scope.



Facility files will be stored electronically and can be reviewed at any time.

There is a laundry room with washer and dryer in place and ready for use. Laundry area has locking cabinets for laundry supplies.

There is a dining room with table and chairs for clients to use. LPA observed large sectional sofa in the common area that provides ample seating for the clients.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIERRA HEALTH AND WELLNESS-BANGOR
FACILITY NUMBER: 045920157
VISIT DATE: 09/24/2024
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Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave and refrigerator were all present and ready for use.

The facility has (3) fully charged fire extinguisher which were inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning. Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. Each client room has towels and face cloths available for the clients to use.


Storage and lighting are adequate in the home. Medications are to be locked up in a cabinet. Cleaning supplies and toxins will be locked up in supply room. Also locked in the kitchen are knives.

There is gazebo with outdoor furniture for the clients to use in the front yard.

The applicant has passed the pre-licensing portion of the application process. A copy of the report was provided to administrator Lorna Pham. LPA will contact the Central Application Bureau.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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