<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700588
Report Date: 10/31/2022
Date Signed: 10/31/2022 10:26:11 AM


Document Has Been Signed on 10/31/2022 10:26 AM - 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: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: DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Scott AfableTIME COMPLETED:
10:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst ()Cassie Yang arrived at the facility unannounced on 10/31/2022 to conduct a Annual Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. LPA observed the facility to have ample supply of PPE. LPA observed (5) residents present at the facility. LPA observed the fire extinguisher to be last serviced 5/12/2022. LPA observed sharps, toxics and medication to be locked and secured. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. LPA and Administrator completed the infection control domain. At this time, facility was found to be in compliance.

During today's inspection, Administrator inquired information regarding license for 8 bed facility. LPA requested the following records: Resident Roster, LIC 500, LIC 308, Administrator Certificate and Liability Insurance by Friday November 4, 2022.

As a result of this visit, no deficiencies are being cited. Exit interview conducted and copy of report was provided via email.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1