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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001818
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:42:23 AM


Document Has Been Signed on 01/26/2023 11:42 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GOLD AGE VILLAFACILITY NUMBER:
315001818
ADMINISTRATOR:OSELSKY, RAISAFACILITY TYPE:
740
ADDRESS:8100 HORSESHOE BAR ROADTELEPHONE:
(916) 652-0348
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:6CENSUS: 5DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Raisa OselskyTIME COMPLETED:
12:00 PM
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LPA Parks arrived on Thursday January 26, 2023 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.

LPA and Licensee completed the infection control domain together and facility was found to be in substantial compliance at this time.

LPA and Licensee toured the facility together to ensure health and safety of residents in care. In the areas toured, no immediate health, safety, or personal rights violations were observed.

No deficiencies are being cited as a result of todays inspection. 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: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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