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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700455
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:50:03 PM


Document Has Been Signed on 06/02/2022 04:50 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:AAA SENIOR CAREFACILITY NUMBER:
312700455
ADMINISTRATOR:MICHAEL DEMYANFACILITY TYPE:
740
ADDRESS:1998 CLARK TUNNEL RDTELEPHONE:
(916) 222-1406
CITY:PENRYNSTATE: CAZIP CODE:
95663
CAPACITY:6CENSUS: 5DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Michael DemyanTIME COMPLETED:
05:00 PM
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On 6/2/2021 LPA Tryon arrived at the facility unannounced to complete an annual visit using The Infection Control Domain of the CARES tool. LPA met with Administrator Michael Demyan.
LPA toured the facility including common areas, dining area, bedrooms, bathrooms, laundry room, kitchen, and Yard. Each resident has a private bedroom which is nicely furnished.

The home appears to be well-furnished, clean, and in good repair. Food supplies are adequate and of good quality and variety. The facility has adequate supplies of PPE, cleaners, etc.

LPA reviewed the Infection Control Domain. No issues or deficiencies noted at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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