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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700944
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:21:06 AM


Document Has Been Signed on 11/03/2022 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: 5DATE:
11/03/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Queenie RamonsTIME COMPLETED:
11:30 AM
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LPA Parks arrived on Thursday October 3, 2022 to complete 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.

LPA completed the infection control domain with Administrator Queenie and facility was found to be in substantial compliance. LPA and Administrator toured the facility together to ensure health and safety of residents in care.

LPA requested copies of current LIC500, LIC610, and current liability insurance to be sent to the Department by the end of the month.

No deficiencies are being cited as a result of todays visit. 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: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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