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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002853
Report Date: 11/01/2022
Date Signed: 11/01/2022 12:06:38 PM

Document Has Been Signed on 11/01/2022 12:06 PM - 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:SIGNATURE LIVING ON CAMELIA AVENUEFACILITY NUMBER:
315002853
ADMINISTRATOR:OCAMPO, JESSEFACILITY TYPE:
740
ADDRESS:904 CAMELIA AVETELEPHONE:
(916) 899-5880
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
11/01/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jesse OcampoTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to conduct a required annual.
LPA met with , Administrator on call arrived to the facility. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA reviewed 2 resident files and 1 staff file.

LPA advised Staff and Resident files be on site and complete, FIT test employees who may work with Covid residents, maintain fire drill records on site.

There are no deficiencies issued during today's inspection.
Exit interview. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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