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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 251370262
Report Date: 09/17/2021
Date Signed: 09/17/2021 08:19:45 AM

Document Has Been Signed on 09/17/2021 08:19 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:MODOC WORK ACTIVITY CENTERFACILITY NUMBER:
251370262
ADMINISTRATOR:MITCHELL, PAULFACILITY TYPE:
775
ADDRESS:310 WEST C STTELEPHONE:
(530) 233-4527
CITY:ALTURASSTATE: CAZIP CODE:
96101
CAPACITY: 30CENSUS: DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Paul MitchellTIME COMPLETED:
09:00 AM
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09/17/2021 8:00 AM Licensing Program Analysts (LPAs) Misty Valencia and Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Program Administrator Paul Mitchell and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask, Additionally, LPAs was screened by staff at the front door.

LPAs, and Mr. Mitchell toured the facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, three (3) bathrooms, isolation room, and the kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs, and Mr. Mitchell 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 report emailed to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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