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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185002039
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:02:52 PM

Document Has Been Signed on 06/08/2022 03:02 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:ZAMORA RESIDENCEFACILITY NUMBER:
185002039
ADMINISTRATOR:MOTTS, ALICIAFACILITY TYPE:
735
ADDRESS:406 RUSSELL AVENUETELEPHONE:
(530) 251-8442
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 6CENSUS: 6DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sara Williams, AdminsitratorTIME COMPLETED:
12:00 PM
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6/08/2022 Licensing Program Analyst (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator Sara Williams 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; contacted administrator 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: Surgical Mask

LPA Valencia and Ms. Williams toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (2) two bathrooms, (4) bedrooms kitchen and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Valencia 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.

Exit interview conducted and copy of report was emailed to administrator Sara Williams.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
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)
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