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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097004177
Report Date: 07/21/2022
Date Signed: 07/22/2022 09:21:20 AM


Document Has Been Signed on 07/22/2022 09:21 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:PONTE PALMEROFACILITY NUMBER:
097004177
ADMINISTRATOR:KASNER, GREGORYFACILITY TYPE:
740
ADDRESS:3083 PONTE MORINO DRIVETELEPHONE:
(530) 677-9100
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:250CENSUS: 169DATE:
07/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Eric Olson, Executive DirectorTIME COMPLETED:
12:25 PM
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07/21/2022 12:00 PM Licensing Program Analyst (LPA) Williams, made an unannounced visit to the administrative office and met with Eric Olson, Executive Director. Prior to initiating 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA served order of immediate exclusion, spoke to director and explained the "Immediate Exclusion" notice indicating that S1 cannot be allowed to work, be present and/or live in a CCL licensed facility or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Eric Olson, Executive Director, indicated they understood the notice and confirmed that S1 was officially terminated from employment.



Exit interview completed. Copy of report was emailed to Eric Olson, Executive Director.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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