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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700588
Report Date: 10/13/2021
Date Signed: 10/13/2021 12:27:06 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:SIGNATURE LIVING ON WINDING WAYFACILITY NUMBER:
342700588
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6258 WINDING WAYTELEPHONE:
(916) 812-0944
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Scott Afable, Administrator TIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Placida "Bing" De Vera and Jocelyn Streeter, caregivers, and explained purpose of inspection. LPA was screened LPA upon entrance. Caregiver Bing contacted Administrator, Scott Afable, by phone, who arrrived at approximately 11:30 am. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. LPA confirmed there are (4) residents currently at the facility and (1) resident is currently at the hospital.

LPA and caregiver toured the interior of the facility and observed it to be clean and in good repair. LPA observed all (4) residents to be in their room resting. Rooms toured include (5) private bedrooms and (1) vacant room, (2) bathrooms, kitchen and common areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 75* F. Fire extinguisher last serviced 5/16/2021. LPA observed sufficient 2+day perishable and 7+day non-perishable food on site. LPA observed paper towels, soap and sanitizer in the bathrooms. LPA discussed and obtained recent paperwork for a resident who had an appointment on Monday, 10/11/2021. All staff are associated or requested to be associated previously- Admin showed LPA verification- request was resent today.

There were no deficiencies observed during today's inspection.

Exit interview. Copy of report to be emailed to Administrator following inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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