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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700214
Report Date: 12/01/2022
Date Signed: 12/23/2022 08:49:48 AM

Document Has Been Signed on 12/23/2022 08:49 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WILSON HOME, THEFACILITY NUMBER:
092700214
ADMINISTRATOR:JESSICCA WILSONFACILITY TYPE:
735
ADDRESS:4310 OAK VIEW DRIVETELEPHONE:
(530) 363-2631
CITY:PILOT HILLSTATE: CAZIP CODE:
95664
CAPACITY: 6CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:TIME COMPLETED:
04:00 PM
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LPA Tryon arrived at the facility on 12/1/2022 to perform an annual visit using the Infection Control Domain of the CARES Tool. Prior to the visit, LPA did a self-screening by taking temperature and reviewing symptoms. LPA wore a surgical mask and used hand sanitizer.

LPA met with Elliott Wilson.

LPA toured the facility including common areas, dining room, resident bedrooms, bathrooms, hallways, , yard. There appears to be a good supply of PPE, soap, paper towels, cleaners, etc. There is a good supply of perishable, frozen and canned/dry goods food. The facility appears to in good repair.

LPA reviewed the infection control domain with the Administrator. Infection Control Plan is in place.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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