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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292700174
Report Date: 05/26/2021
Date Signed: 06/11/2021 03:32:42 PM

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:BRUNSWICK VILLAGEFACILITY NUMBER:
292700174
ADMINISTRATOR:LAINE, KRISTIEFACILITY TYPE:
740
ADDRESS:316 OLYMPIA PARK CIRCLETELEPHONE:
(530) 274-1992
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:100CENSUS: 54DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Kristie LaineTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Williams and Hiratsuka arrived at the facility unannounced on 05/26/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Administrator, Kristie Laine, 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 and contacted licensee 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: N-95 Respirator and surgical mask, respectively. Additionally, LPAs were screened by facility staff upon entering the facility.

LPAs and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, numerous bathrooms, kitchen, dining room and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and 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 left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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