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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001734
Report Date: 03/24/2022
Date Signed: 03/25/2022 09:42:02 AM


Document Has Been Signed on 03/25/2022 09:42 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:PINECREST RETIREMENT HOMEFACILITY NUMBER:
315001734
ADMINISTRATOR:MOKTAN, BIRBAHADURFACILITY TYPE:
740
ADDRESS:107 PINECREST AVENUETELEPHONE:
(530) 885-8203
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Birbahadur (Danny) MoktanTIME COMPLETED:
04:15 PM
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LPA Tryon arrived at the facility on 3/24/2022 to perform an annual visit using the Infection Control Domain. Prior to the visit, LPA dffid a self-screening by taking temperature and reviewing possible symptoms. LPA wore a surgical mask and used hand sanitizer. LPA met with Administrator Danny Moktan.

LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, patio, yard.

LPA reviewed the infection control domain with the Administrator.

The facility appears to be in substantial compliance at this time.

Exit interview conducted
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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