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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002322
Report Date: 06/01/2021
Date Signed: 06/01/2021 04:35:44 PM

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:WESTWOOD HILLS SENIOR CARE HOMEFACILITY NUMBER:
315002322
ADMINISTRATOR:LISNAWATI, SHAINAFACILITY TYPE:
740
ADDRESS:521 SILKWOOD DRIVETELEPHONE:
(530) 210-6183
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 5DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shaina Lisnawati (Licensee)TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 6/01/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Shaina Lisnawati (Licensee) and explained the purpose of the visit. Prior to initiating the annual inspection, 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. LPA did not observe a designated screening area, but was informed staff do screen, but do not record. LPA informed staff that documenting screening is required, LPA to send over Screening Questions and facility will implement centralized screening area upon receiving document.

LPA, Admin and Licensee toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, three (3) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and staff completed the infection control domain and facility was found to be in compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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