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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004560
Report Date: 04/12/2022
Date Signed: 04/12/2022 01:08:38 PM

Document Has Been Signed on 04/12/2022 01:08 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: 10DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Orlando PerezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/12/22 to conduct a Annual Inspection utilizing the infection control domain guidance. LPA met with the Director and explained the purpose of the visit. Prior to initiating the 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 completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by caregiver upon entering the facility.

LPA toured the interior and exterior 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, and outside yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Director covered the infection control topics and facility was found to be in substantial compliance at this time.

LPA advised: maintaining visible hand washing signs at all hand washing sinks, maintain record of staff not fully vaxed who require weekly testing, maintain thorough screening of all visitors and staff, purchase trash cans with no touch lids for PPE disposal, routinely review mitigation plan to ensure accuracy/ update as needed.

LPA requested Administrator submit: client roster and staff roster to CCL by 4/19/22.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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