<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310728
Report Date: 02/24/2022
Date Signed: 03/08/2022 02:57:58 PM


Document Has Been Signed on 03/08/2022 02:57 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:VINSON'S CARE HOMEFACILITY NUMBER:
340310728
ADMINISTRATOR:VINSON, CALDONIAFACILITY TYPE:
740
ADDRESS:6121 GILMAN WAYTELEPHONE:
(916) 348-4067
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Markeva EppersonTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Williams arrived on Thursday February 24, 2022 to conduct the annual inspection. Prior to the visit, 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; LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 respirator.

LPA and staff (Administrator was away) toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: kitchen, backyard, bedrooms (3) and bathrooms (2). In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and staff completed the infection control domain together 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. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1