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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
312700739
Report Date:
03/01/2023
Date Signed:
03/01/2023 03:31:13 PM
Document Has Been Signed on
03/01/2023 03:31 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
PINES, THE
FACILITY NUMBER:
312700739
ADMINISTRATOR:
HENRY COLE
FACILITY TYPE:
740
ADDRESS:
500 W RANCHVIEW DRIVE
TELEPHONE:
(916) 672-5019
CITY:
ROCKLIN
STATE:
CA
ZIP CODE:
95765
CAPACITY:
142
CENSUS:
127
DATE:
03/01/2023
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
03:00 PM
MET WITH:
Henry Cole, Administrator
TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with administrator Henry Cole during today's inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.
LPA received an incident report from facility that on 2/10/23 R1 was found on the floor and was complaining of neck pain. R1 was then sent out to the emergency room and returned later that day. R1 had a diagnosis of a lumbar spinal fracture and received an new medication order for pain. R1 is doing well and has not had a reoccurring fall. This was R1's first fall at the facility since admission.
No deficiencies are being cited as a result of todays inspection.
Exit interview conducted.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Bethany Mirlohi
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
03/01/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/01/2023
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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