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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700370
Report Date: 07/13/2021
Date Signed: 08/11/2021 09:18:49 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:PRAIRIE CITY LANDINGFACILITY NUMBER:
342700370
ADMINISTRATOR:MARTIN, CHERYL KFACILITY TYPE:
740
ADDRESS:645 WILLARD DRTELEPHONE:
(916) 458-0303
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:200CENSUS: 128DATE:
07/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cheryl Martin (Admin)TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility to conduct a Case Management Visit. Community Care Licensing (CCL) received an Incident Report (LIC 624) and Report or Suspected Dependent Adult/Elder Abuse (SOC 341) from facility regarding R1's attempted suicide. Prior to initiating the annual 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. Upon entry, LPA was screened by Staff and was greeted by Cheryl Martin (Admin). LPA then explained the purpose for the visit to admin.

During the Case Management Visit, LPA conducted interviews with Admin, S1, and R1; as well as reviewed R1’s Physician’s Report (LIC 602) and Charting Notes for the last two (2) weeks. Admin is to send LPA the weekly “check-in” notes by COB 7/16/2021.

No deficiencies are being cited as a result of today’s visit.

Exit interview conducted and report left at facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
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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