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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001897
Report Date: 12/17/2021
Date Signed: 12/17/2021 03:23:03 PM

Document Has Been Signed on 12/17/2021 03:23 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:SIERRA SUMMIT HEAD INJURY CAREFACILITY NUMBER:
317001897
ADMINISTRATOR:PENNY MEARSFACILITY TYPE:
735
ADDRESS:5562 MONTCLAIR DRIVETELEPHONE:
(916) 632-9622
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 4DATE:
12/17/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Penny Mears, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 12/17/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Penny Mears, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 4 bedrooms and 2 bathrooms for residents, common area, dining room, food supply, medication room, PPE supply, garage, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA received updated documentation from facility, including Administrator Certificate and LIC 308. Facility will submit a copy of their Liability Insurance and Control of Property to LPA via email.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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