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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297004085
Report Date: 11/01/2021
Date Signed: 11/01/2021 12:53:30 PM

Document Has Been Signed on 11/01/2021 12:53 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:YOUNGER'S RESIDENTIAL CAREFACILITY NUMBER:
297004085
ADMINISTRATOR:YOUNGER, SHARIFACILITY TYPE:
735
ADDRESS:10820 CONIFER LANETELEPHONE:
(530) 273-7765
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 6CENSUS: 6DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Shari YoungerTIME COMPLETED:
12:30 PM
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LPA Lusby arrived on Monday November 1, 2021 to conduct the annual inspection. 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 and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time. LPA to drop off additional PPE at the facility next week.

LPA and Administrator toured facility together to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. Due to computer issues, LPA was unable to have Administrator sign 809. LPA to email finalized 809 to Administrator. A hard copy will be kept in the facility file.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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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