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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002963
Report Date: 12/22/2022
Date Signed: 12/22/2022 03:09:15 PM

Document Has Been Signed on 12/22/2022 03:09 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:NORTHPARK MANORFACILITY NUMBER:
315002963
ADMINISTRATOR:IACOB, GEORGETAFACILITY TYPE:
740
ADDRESS:1525 NORTHPARK DRTELEPHONE:
(916) 849-7327
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 0DATE:
12/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Georgeta IacobTIME COMPLETED:
04:00 PM
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On 12/22/2022 LPA Tryon visited the facility to do a pre-licensing visit. LPA met with applicant Georgeta Iacob and Vasile Jacob.

LPA toured the facility including living room, sitting room, kitchen, dining area, hallways, bedrooms, staff bedroom and bathroom, bathrooms, storage, garage, and yard. The home is all re-modeled and nicely furnished throughout. There is adequate space for activities inside and outside. Residents will all have single bedrooms. Fire doors were installed at the direction of the Fire Department, and close automatically in the event of a fire. Fire extinguisher present and charged. Smoke detectors/carbon monoxide detector installed. The kitchen is completely furnished with pots/pans, dinnerware, flatware, cups/glasses, etc. There is plenty of non-perishable food available. The facility has ramps on outside exits as needed. No tripping hazards, etc. noted. Activities present.

LPA reviewed the Pre-licensing version of the CARES Tool with applicant. The applicant has appropriate staff and resident paperwork/folders available. Appropriate posters are posted including rights, where to call with complaints/issues, COVID posters, exit plans, etc

LPA is waiving the requirement for RCFE Orientation Part III session, as the applicants have been involved in the business and owned, run and worked in several different RCFE facilities over the past 20 years; and they are very familiar with regulations, requirements and day to day operation of facilities.

No issues were noted in the facility. The facility appears to be in substantial compliance and be ready to open.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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