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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 090312052
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:17:21 AM

Document Has Been Signed on 05/12/2022 10:17 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:MOTHER LODE REHABILITATIONFACILITY NUMBER:
090312052
ADMINISTRATOR:DAVIES, SUSIEFACILITY TYPE:
775
ADDRESS:399 PLACERVILLE DRIVETELEPHONE:
(530) 622-4848
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY: 250CENSUS: 27DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Susie Daves, CEOTIME COMPLETED:
10:45 AM
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On May 12, 2022, Licensing Program Analysts (DeAnna Williams-Lyons arrived at the facility to conduct the facilities Required Year Inspection utilizing the infection control domain, LPA met with Susie Davies (CEO) and explained the purpose of the visit. Prior to initiating the annual inspection, LP 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally LPA were screened upon entry and completed self affirmation.

LPA and staff toured facility together to ensure health and safety of clients in care. During visit, LPA toured the entirety of facility grounds. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and CEO was not able to complete the infection control domain questionnaire however facility was found to be in substantial compliance at this time.

CEO submitted the emergency disaster Plan and a copy of their liability insurance.


No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left with Susie..
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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