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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002961
Report Date: 01/25/2023
Date Signed: 01/25/2023 10:57:32 AM


Document Has Been Signed on 01/25/2023 10:57 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:SPRING GARDEN CARE HOME, LLCFACILITY NUMBER:
315002961
ADMINISTRATOR:BOT, MELISAFACILITY TYPE:
740
ADDRESS:1901 GREAT DIVIDE CT.TELEPHONE:
(916) 868-4402
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 0DATE:
01/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melisa Bot, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived announced to conduct a pre-licensing inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

Facility was inspected both indoors and outdoors. LPA inspected 6 resident bedrooms, 1 staff room, 2 bathrooms, common living areas, garage and kitchen. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. First aid kit was present in the facility. Centrally stored medications will be locked in the kitchen area cabinet. The facility has adequate lighting throughout and night lights in the hallways. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. LPA observed grab bars and non-skid mats present in the bathrooms. Smoke detectors and carbon monoxide detectors were checked and operational. Fire clearance was granted on 09/20/22 for 5 non-ambulatory and 1 bedridden resident. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for resident use.

Competent III was completed during today's inspection with licensee. Licensee is required to contact Community Care Licensing upon the admittance of their first consumer, after licensure. This report will be forwarded to the centralized application unit for continued processing.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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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