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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700848
Report Date: 09/26/2022
Date Signed: 09/27/2022 09:09:37 AM


Document Has Been Signed on 09/27/2022 09:09 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/27/2022 09:02 AM

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

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On 9/26/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required 1-Year annual inspection. LPA met with Administrator, David Antone, and Manager, Ioana Antone, and explained the purpose of the visit. 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 Manager toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured included but not limited to: kitchen, laundry room, garage, backyard and common areas. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA observed all visitors to be screened upon entry. LPA observed the backyard to be in good repair. LPA observed the kitchen to have 2+ days of perishable and 7+ days of non-perishable. LPA observed the facility to have ample supply of PPE. LPA observed medications, sharps and toxics to be locked and secured. LPA was informed Administrator Certificate is expired, but has been pending renewal for a few months. Administrator informed LPA proof of renewal will be emailed to LPA. LPA reviewed Co-Administrator, Domnita Niculai, to be current. LPA and Manager completed the infection control domain and facility was found to be in compliance at this time.

LPA requested a copy of the LIC 308, LIC 500, proof of Administrator Certificate renewal, and current liability insurance.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
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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