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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700484
Report Date: 01/10/2023
Date Signed: 01/10/2023 07:23:35 PM

Document Has Been Signed on 01/10/2023 07:23 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:RELIANCE CARE #5FACILITY NUMBER:
342700484
ADMINISTRATOR:TRINH, HONGFACILITY TYPE:
740
ADDRESS:5220 EL CAMINO AVETELEPHONE:
(916) 696-6867
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
01/10/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Rebecca McFaddenTIME COMPLETED:
07:30 PM
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On 1/10/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility and spoke with Administrator, Rebecca McFadden. The purpose of this visitation was a Plan of Correction (POC) visit regarding the citations issued on 12/22/2022, as a result of the case management visit.

Prior to initiating today's visitation, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured the following Personal Protective Equipment (PPE) was worn: surgical mask.

During today's visit, LPA cleared the following citations:

87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

An exit interview was conducted and copy of report and appeal rights was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023
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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