<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 290311983
Report Date: 12/02/2021
Date Signed: 12/02/2021 10:47:22 AM

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:SIERRA GUEST HOMEFACILITY NUMBER:
290311983
ADMINISTRATOR:RICHARD CULLENFACILITY TYPE:
740
ADDRESS:131 GLENWOOD AVENUETELEPHONE:
(530) 273-3163
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:15CENSUS: 9DATE:
12/02/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Heidi WolkenTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Lusby arrived on Thursday December 2, 2021 to conduct the final walk through. Prior to 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA verified that all assisted living clients had relocated to other facilities. Currently there are 9 clients. 2 clients have services through IHSS. 7 other clients do not require any care services. Facility staff serve food, clean, and provide laundry services. Facility is operated by Foothills House of Hospitality.

LPA toured the facility with staff Heidi.

LPA will close out the facility in LIS.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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 1