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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700944
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:21:55 AM


Document Has Been Signed on 10/31/2022 11:21 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:A LOVING SENIOR CARE HOME I LLCFACILITY NUMBER:
312700944
ADMINISTRATOR:RAMOS, QUEENIE R.FACILITY TYPE:
740
ADDRESS:501 HEATHMORE CT.TELEPHONE:
(510) 427-9904
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Vicky EspirituTIME COMPLETED:
11:30 AM
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LPA Parks arrived on Monday October 31, 2022 to conduct the annual inspection. Prior to 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: N-95 mask.

Due to time constraints, LPA was unable to complete the visit. The annual inspection will be completed at a future date.

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: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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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