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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700184
Report Date: 07/19/2021
Date Signed: 07/19/2021 04:00:06 PM

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:SHEARWATER RESIDENCEFACILITY NUMBER:
342700184
ADMINISTRATOR:THOMAS, REBECCAFACILITY TYPE:
740
ADDRESS:6526 MAIN AVETELEPHONE:
(916) 989-1060
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:16CENSUS: 12DATE:
07/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Becky Thomas, administratorTIME COMPLETED:
04:10 PM
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Community Care Licensing (CCL) staff Mariya Melnichuk and Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/19/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with med-tech Jesse Soliz and explained the purpose of the visit. Med-tech contacted administrator who gave verbal permission for visit to be started with med-tech.

Prior to initiating the annual inspection CCL staff and LPA completed required COVID-19 testing protocols, and self-screened for symptoms of COVID-19. Additionally LPA contacted facility and conducted a pre-screening call prior to inspection. CCL staff and LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical masks. LPA and CCL staff were screened by facility staff upon arrival.

CCL staff, LPA, and med-tech toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident rooms, bathrooms, activity space, breakroom, pantry, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed.

Administrator Becky Thomas arrived later and completed inspection with CCL. LPA and administrator 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 and copy of report left at the facility.

Administrator to send in updated copy of LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, and current copy of Liability Insurance to update facility file to Community Care Licensing by 07/26/2021.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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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