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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700808
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:08:08 PM


Document Has Been Signed on 10/27/2022 02:08 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:PACIFIC COAST CARE HOMESFACILITY NUMBER:
312700808
ADMINISTRATOR:ZAIDI, MARIAFACILITY TYPE:
740
ADDRESS:4470 ROLLING OAKS DRIVETELEPHONE:
(916) 823-3902
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 6DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Oscar de la RosaTIME COMPLETED:
02:30 PM
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On Thursday October 27, 2022, Licensing Program Analyst (LPA) Melissa Parks conducted a case management visit to the facility for the purpose of delivering an Order to Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion from Facility.

Prior to initiating the visit, 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. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. LPA completed the facility screening questionnaire.

LPA Parks spoke with Administrator Maria Zaidi on the phone and explained the purpose of today's visit. Maria explained that this employee was terminated from this facility in July 2021. Maria gave permission for staff Oscar to sign this report.

Sa A Tuli, Staff Person is excluded as of this date 10/27/2022.

LPA Parks handed the Order to Licensee/Facility of Immediate Exclusion from the Facility and explained that staff person Sa A Tuli cannot be allowed to work, be present and/or live in a Community Care Licensing (CCL) licensed facility or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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