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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005563
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:35:40 PM


Document Has Been Signed on 01/31/2023 12:35 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:HAMPSHIRE MANOR INCFACILITY NUMBER:
317005563
ADMINISTRATOR:CATHY DUSTINFACILITY TYPE:
740
ADDRESS:1203 HAMPSHIRE COURTTELEPHONE:
(916) 742-5386
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Cathy Dustin- AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 01/31/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Cathy Dustin, and explained the purpose of the visit.LPA ensured they applied hand sanitizer and washed hands 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 and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, four (4) bathrooms, kitchen, and backyard. 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.

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

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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