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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700445
Report Date: 05/11/2022
Date Signed: 09/30/2022 02:01:06 PM


Document Has Been Signed on 09/30/2022 02:01 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:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
092700445
ADMINISTRATOR:MELISA TIBURCIOFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:64CENSUS: DATE:
05/11/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Melisa Tiburcio, Executive DirectorTIME COMPLETED:
10:15 AM
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On May 11, 2022, Licensing Program Analyst (LPA) DeAnna William s-Lyons arrived unannounced to conduct an annual inspection. LPA met with Melisa Tiburcio, Executive Director, and informed her the reason for the visit.

Prior to the visit, LPA 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 Mask.

Melisa and LPA conducted the infectious control questionnaire with no issues.
Administrators certificate is current expiring ________________
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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