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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005915
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:27:12 AM

Document Has Been Signed on 09/21/2022 11:27 AM - 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:DAYCATION FOR SENIORSFACILITY NUMBER:
317005915
ADMINISTRATOR:KELLY, PAULFACILITY TYPE:
775
ADDRESS:6011 STANFORD RANCH DR #104TELEPHONE:
(916) 698-7555
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 60CENSUS: 24DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Paul KellyTIME COMPLETED:
11:45 AM
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On 9/21/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required 1-Year annual inspection. LPA met with Administrator, Paul Kelly, and explained the purpose of the visit. Prior to today's inspection, LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Administrator toured the interior of the facility including the staff office, conference room, quiet room, activity room, restrooms, kitchen, storage room and common area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed the clients to be in the common area, sitting in a circle playing instruments and singing together. LPA observed the door to the kitchen and supply/storage room to be locked with a key pad lock. Fire extinguishers last serviced 5/11/2022. LPA observed paper towels, soap and hand washing signs in restroom. LPA observed sharps and toxics to be locked and secured. LPA observed the medications to be locked and secured at the receptionist desk. LPA observed the facility to have ample supply of arts and crafts for clients. LPA and Administrator followed the infection control domain guidelines and facility was found to be in substantial compliance at this time.

LPA reviewed staff personnel files and obtained copies of the Staff Monthly Work Schedule of September and the LIC 308.

As a result of today's inspection, no deficiencies were observed.

An exit interview was conducted and a copy of the report was left at the facility with Administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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