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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097003223
Report Date: 06/08/2022
Date Signed: 06/16/2022 09:27:32 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/16/2022 09:27 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:PINE TREE VILLAFACILITY NUMBER:
097003223
ADMINISTRATOR:LYNN RELOZAFACILITY TYPE:
740
ADDRESS:3353 CIMMARRON ROADTELEPHONE:
(530) 672-9080
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:15CENSUS: 11DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Hazel Cabiner, Care StaffTIME COMPLETED:
09:58 AM
NARRATIVE
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On June 8, 2022, at 9am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Required 1 Year Annual inspection. LPA met with Hazel staff after finding out that facility has a person positive for Covid-19. LPA briefly scanned the facility from the outside and told the staff LPA will call the administrator on the phone and will conduct the rest of the annual inspection via teleconference to complete the Infectious Control questionnaires. LPA was not able to contact the administrator by teleconference on today's date. LPA will contact the administrator by telephone on tomorrow's date

LPA returned to the facility on 6/16/2022 to complete the Annual inspection. LPA met with their fire extinguishers, smoke alarms first aid kit and water temperature. All were good except the water temperature. It measured 131 degrees F. LPA will call the administrator to complete the infectious Control questionnaire,

There was a deficiency found during today’s inspection. Deficiency is cited from California Code of regulations, Title 22, Division 6, 8 and the citation is listed on the attached LIC 809 D page.staff who informed me that 2 additional residents had Covid-19. LPA entered and checked

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than July 16, 2022.

An exit interview was conducted and a copy of this report was given to staff, Hazel
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/16/2022 09:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: PINE TREE VILLA
FACILITY NUMBER: 097003223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited

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Maintenance and Operation.
Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F.
LPA observed that the hot water dispensed in the restroom faucets were measured at 131, above the max level of 120 degrees.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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