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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700243
Report Date: 07/13/2021
Date Signed: 07/15/2021 09:21:39 AM

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:CHAUPPETTE ASSISTED LIVING LLCFACILITY NUMBER:
342700243
ADMINISTRATOR:CHAUPPETTE, SHEREEFACILITY TYPE:
740
ADDRESS:6813 MARINVALE DRIVETELEPHONE:
(916) 560-8708
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 5DATE:
07/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angie ChavezTIME COMPLETED:
04:30 PM
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LPA Tryon arrived at the facility to do a case manangement visit regarding an Incident Report dated 6/3/2021.

On that date resident R1 started saying she did not want to be at the home, she did not want to be a prisoner. She packed her things and the facility contacted her ex-husband who had placed her at the home. The ex-husband came to the home and picked her up.

In reviewing the resident's Physician Report, it does state that she is not able to go out on her own. However, R1 did not leave the facility on her own. Her husband, who had placed her at the facility, came and picked her up and took responsibility for her. She was never out on her own during this incident, and went right from the home to her husband's care. The home did not have any other responsible parties or POA listed for the resident.

It appears that the facility reacted appropriately by contacting her responsible party, and the resident went with him.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
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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