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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310728
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:22:56 AM


Document Has Been Signed on 04/14/2022 10:22 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
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: 0DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Deontee VinsonTIME COMPLETED:
10:29 AM
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Licensing Program Analyst (LPA) Jacob Williams arrived at the facility on 04/14/2022 to conduct a Case Management Inspection proceeding the closure of the facility. LPA met with staff, Deonte Vinson, and explained the purpose of the visit. Prior to initiating the Case Management 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 LPA completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA observed that there were no residents at the facility. LPA toured the interior and exterior of the facility. Areas toured include but are not limited to: common areas, five (5) residents bedrooms, two (2) bathrooms, kitchen, backyard.

LPA was handed over original license at time of visit.

Exit interview conducted and a copy of the report will be provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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