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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002796
Report Date: 06/24/2021
Date Signed: 06/24/2021 11:43:34 AM

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:SWAN LAKE VILLAFACILITY NUMBER:
315002796
ADMINISTRATOR:MAKANONENG, ANDREWFACILITY TYPE:
740
ADDRESS:9702 SWAN LAKE DRTELEPHONE:
(916) 797-8521
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:7CENSUS: 0DATE:
06/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Andrew MakanonengTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility announced on 06/24/2021 to conduct an announced prelicensing visit LPA met with Facility Representative Andrew Makanonengand explained the purpose of the visit. Prior to initiating the prelicensing 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; contacted Facility Representative 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: surgical mask. Additionally, LPA was screened by Andrew Makanoneng.
This facility has a fire clearance for seven non-ambulatory residents. This facility has seven private resident rooms and all but one room has an exit to the outside. The main entrance opens to a sitting area on both sides and there is an office set-up on the right. Across the main entrance is the only hallway that has the kitchen and dining on the left, a full common bathroom on both sides, two resident rooms on the left, and five resident rooms on the right. Two of the resident rooms on the right have private half bathrooms. The hallway leads to another common area in the back. This facility has a second floor that has one room and a full private bathroom and is not accessible to residents. The garage is connected to the facility by a door on the right sitting area.. The garage is used for storage. There are also two rooms in the garage that are not to be used for sleeping quarters for staff. The two rooms may be used as break rooms or storage.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SWAN LAKE VILLA
FACILITY NUMBER: 315002796
VISIT DATE: 06/24/2021
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The backyard was inspected. There are gates on both sides of the facility. There are three locked sheds on right of the facility. There are gates on both sides of the facility. The exit to the backyard exits to a wood patio that is well maintained. There is a little sitting area in front of the main entrance.

Component III orientation was conducted during this visit

Multiple topics were discussed during this visit.

This facility meets regulations. LPA is going to submit this report to the applications specialist.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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