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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004560
Report Date: 08/24/2021
Date Signed: 08/24/2021 01:43:15 PM

Document Has Been Signed on 08/24/2021 01:43 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:REACH ADULT DEVELOPMENT SITE #5FACILITY NUMBER:
317004560
ADMINISTRATOR:SUH, SEANFACILITY TYPE:
775
ADDRESS:9980 NIBLICK DRTELEPHONE:
(916) 778-8696
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 45CENSUS: 7DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Michael PalmerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/24/21 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Program Director and explained the purpose of the visit. Prior to initiating the annual inspection, 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 and upon arrival completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathroom, kitchen.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Program Director completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA advised facility keep hand sanitizing supplies at the client/guest entry,extend the client/guest screen to include all covid symptoms, create quality assurance that twice daily sanitizing is completed/ documented and that N-95 respirators are Fit tested for all staff.

LPA requested for documents such as, resident roster, LIC 500, the last signature page of the LIC 610E be submitted to LPA via email by due date on, 8/30/21.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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