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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002873
Report Date: 02/28/2023
Date Signed: 02/28/2023 12:41:29 PM

Document Has Been Signed on 02/28/2023 12:41 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CIRBY RANCH SRFFACILITY NUMBER:
315002873
ADMINISTRATOR:OKOLO, SAFARATUFACILITY TYPE:
772
ADDRESS:1085 SANDRINGHAM WAYTELEPHONE:
(916) 870-9676
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 5DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Khalil Khalil- Licensed Psych Technician TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 02/28/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Licensed Psych Technician (LPT), Khalil Khalil, and explained the purpose of the visit. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA were screened by LPT.

LPA toured the interior and exterior of the facility together with LPT. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, one (1) bathrooms, laundry room, kitchen, and garage. LPA and LPT completed the infection control domain together and facility was found to be in substantial compliance at this time. LPA provided LPT summary of PIN 23-02-ASC - UPDATED GUIDANCE ON TESTING, ISOLATION AND QUARANTINE.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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