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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700815
Report Date: 09/21/2022
Date Signed: 09/21/2022 10:34:38 AM

Document Has Been Signed on 09/21/2022 10:34 AM - 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:PRIME ADULT DEVELOPMENT INCFACILITY NUMBER:
312700815
ADMINISTRATOR:CHENKO, TANYAFACILITY TYPE:
775
ADDRESS:5935 PACIFIC STREETTELEPHONE:
(916) 740-5577
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 30CENSUS: 14DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Sargis Melisetyan and Tanya ChenkoTIME COMPLETED:
10:40 AM
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On 9/21/2022, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced to conduct a Required 1-Year annual. LPA met with manager, Sargis Melisetyan who contacted Administrator, Tanya Chenko, who arrived to the facility shortly afterwards. Prior to today's inspection, LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Administrator toured the interior of the facility including the staff office, conference room, computer room, quiet room, (2) activity room, restroom, kitchen, storage room and common area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed paper towels, soap and hand washing signs in restroom. LPA observed toxics to be locked and secured. Administrator informed LPA clients do not take medications at the facility. Administrator informed LPA there are no sharps at the facility, only plastic knives. Fire extinguishers last serviced 6/8/2022. LPA observed the facility temperature to be at 76*. LPA observed the Administrator Certificate #6002598735 to be up to date with expiration 5/23/2023. LPA and Administrator followed the infection control domain guidelines and facility was found to be in substantial compliance at this time.

LPA obtained a copy of the current Administrator Certificate, liability insurance, activity calendar, LIC 500 and LIC 308. No other documents are requested at this time.

As a result of today's inspection, there were no deficiencies observed.

Exit interview conducted and a copy of the report was left at the facility.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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