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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700709
Report Date: 01/25/2022
Date Signed: 01/25/2022 05:01:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/25/2022 05:01 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:SIGNATURE LIVING ON MILLPORT DRIVEFACILITY NUMBER:
312700709
ADMINISTRATOR:KRIEG, NERRYROSEFACILITY TYPE:
740
ADDRESS:7641 MILLPORT DRIVETELEPHONE:
(916) 580-3265
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Nerryrose KreigTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/25/22 to conduct a Required-1 Year Inspection referencing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual 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 and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

LPA toured the facility together with staff to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator arrived at the facility. LPA and completed the infection control domain and facility was found to be in substantial compliance at this time. Clean safe and sanitary with required food.

LPA advised Administrator to clear pathways and fix gate, there should be no shared hand drying towels and that licensee receive verification that magnetic door stops in use are approved by fire department..


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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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