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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 12/20/2021
Date Signed: 12/20/2021 03:22:33 PM

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:BERKELEY, LORIFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: 59DATE:
12/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Amanda Farley, H.R Coordinator,TIME COMPLETED:
03:45 PM
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A case management was conducted today to address the newly appointed interim Administrator, Melinda Clevenger-Klick.LPA met with Amanda Farley, H.R Coordinator, and explained the reason for the visit. Prior to visit, LPA completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19, contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and worn a mask for Personal Protective Equipment (PPE
Ms. Clevenger-Klick was issued an exclusion order on May 3, 2021 stating that Ms. Klick is excluded from being present in any licensed facility by Community Care Licensing. In addition, effective May 3, 2021, Ms. Klick’s Administrator certificate was revoked. The Department advised the licensee that Ms. Klick is not to be present in the facility and that the Licensee will need to appoint a new Administrator within 24 hours of this report.

The facility is not cited during this visit as the facility was able to associate Ms. Klick due to a system error and therefore was not aware at the time of hire of Ms. Klick’s exclusion.

No deficiencies are cited during today’s visit.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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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