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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:08:23 PM


Document Has Been Signed on 10/11/2022 03:08 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:ANSEL PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR:JAMES STACYFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: 68DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Deborah TaylorTIME COMPLETED:
03:15 PM
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 On 10/11/22, Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to conduct a required 1 year inspection. LPA met with Deborah Taylor, Executive Director, and explained purpose of inspection. Prior to initiating the 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. Upon arrival, 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. Additionally, LPA was screened by the front desk personnel upon arrival.
LPA toured the interior of the facility together with the Director to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, one resident bedroom,kitchen,staff room, and a med room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.
LPA received: October staff schedule. LPA interviewed R1. LPA requested a copies of LIC 500, LIC 9020 of equivalent resident roster and liability insurance certificate for 2022-2023 to be submitted by 10/18/22.
LPA advised reestablishing visitor policy notification at the point of entry and increased infection control postings to continue staff and resident awareness of current recommended measures.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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