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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310300209
Report Date: 11/12/2021
Date Signed: 11/12/2021 09:51:07 AM

Document Has Been Signed on 11/12/2021 09:51 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:ERICKSON'S FAMILY CARE HOMEFACILITY NUMBER:
310300209
ADMINISTRATOR:MAXWELL, LINDAFACILITY TYPE:
735
ADDRESS:356 WEST WISE ROADTELEPHONE:
(916) 645-2508
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: 3DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Linda MaxwellTIME COMPLETED:
10:15 AM
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LPA Lusby arrived on Friday November 12, 2021 to conduct the unannounced 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 was screened by Administrator at the entry of the facility. LPA and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time. Clients and staff are fully vaccinated with booster shots. Facility has full supply of PPE.

LPA and Administrator toured the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: resident bedrooms, bathroom, and kitchen. 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. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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