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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700098
Report Date: 12/30/2022
Date Signed: 12/30/2022 04:32:06 PM


Document Has Been Signed on 12/30/2022 04:32 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:CARMICHAEL SENIOR CAREFACILITY NUMBER:
342700098
ADMINISTRATOR:DIZON, MARIA SUSIE VFACILITY TYPE:
740
ADDRESS:5208 FAIR OAKS BLVDTELEPHONE:
(916) 973-9533
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
12/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Alfred Flores and Maria DizonTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility on 12/30/2022 to conduct an annual inspection. LPA met with caregiver, Alfred Flores, and explained the purpose of the visit. Caregiver contacted Administrator who is informed LPA she is currently stuck in traffic.

Prior to entering the facility, LPA ensure she applied hand sanitizer and the following Personal Protective Equipment was worn: surgical mask. At entrance, LPA was screened for COVID-19 symptoms. LPA was informed there are currently five (5) residents in the facility with one (1) on hospice services. LPA reviewed facility license and confirmed there is a hospice waiver of 5.

LPA and caregiver toured the interior of the facility to ensure the health and safety of residents in care. In areas toured no immediate health, safety and personal rights violation were observed. LPA observed (4) residents present in their private rooms, and (1) resident in the common area watching television. LPA observed the pantry to have at least 7+ days of non-perishable foods for the residents in care, and observed caregiver to be preparing rotisserie chicken for dinner. LPA observed medications, sharps and toxics to be locked and secured. LPA observed a bottle of Clorox spray present in the laundry room but was informed by caregiver it is empty and not secured as it needs to be thrown away.



LPA requested a copy of Administrator Certificate, liability insurance, LIC 500 and LIC 308 to be faxed or emailed to LPA by Friday, 01/06/2023.

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

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
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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