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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000716
Report Date: 08/15/2022
Date Signed: 08/15/2022 02:40:25 PM


Document Has Been Signed on 08/15/2022 02:40 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:ELIM GLENFACILITY NUMBER:
317000716
ADMINISTRATOR:LEE, EDWARD INCHULFACILITY TYPE:
740
ADDRESS:6257 EUREKA ROADTELEPHONE:
(916) 791-9451
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:20CENSUS: 19DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Farah Cuccia, CEOTIME COMPLETED:
03:00 PM
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LPA Parks arrived on Monday August 15, 2022 to conduct the annual inspection. Prior to the 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; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA was screened prior to entry into the facility. LPA and CEO Farah completed the infection control domain together and facility was found to be in substantial compliance at this time. LPA and Farah toured facility together to ensure health and safety of residents in care.

LPA requested updated copies of LIC500, LIC610, and current liability insurance to be faxed to LPA by end of the month. LPA obtained a copy of Administrator's current Administrator Certificate.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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