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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297001009
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:01:06 PM

Document Has Been Signed on 05/17/2022 02:01 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:CLAUDIA S. COOK HOMEFACILITY NUMBER:
297001009
ADMINISTRATOR:CLAUDIA S. COOKFACILITY TYPE:
735
ADDRESS:10140 WILD TURKEY LANETELEPHONE:
(530) 432-6983
CITY:SMARTSVILLESTATE: CAZIP CODE:
95977
CAPACITY: 6CENSUS: 4DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jeffery Cooks- Administrator TIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Keosavang arrived at the facility unannounced on 05/17/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrators, Jeffery Cook, 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 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 and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, one(1) bathroom, kitchen, and backyard. 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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