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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115002409
Report Date: 12/16/2021
Date Signed: 12/16/2021 02:22:35 PM

Document Has Been Signed on 12/16/2021 02:22 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:DAVID LEROY MANOR IIFACILITY NUMBER:
115002409
ADMINISTRATOR:NICOLE ELDERFACILITY TYPE:
735
ADDRESS:900 FIFTH STTELEPHONE:
(530) 356-5011
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 6CENSUS: 5DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Nicole Elder - administratorTIME COMPLETED:
02:45 PM
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12/16/2021 1:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator Nicole Elder and explained the purpose of the visit. Prior to initiating the annual inspection, 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: N-95 Mask, gloves. Additionally, LPA Knight was screened by administrator Nicole Elder..

LPA Knight and Ms. Elder toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident rooms, bathrooms, kitchen, storage areas and front yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and the administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection. Technical assistance was provided.

Exit interview conducted and copy of report was emailed to administrator Nicole Elder.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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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