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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700766
Report Date: 08/16/2022
Date Signed: 08/30/2022 02:22:37 PM


Document Has Been Signed on 08/30/2022 02:22 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:YELLOWTAIL HOME CAREFACILITY NUMBER:
342700766
ADMINISTRATOR:LUI, YINGFACILITY TYPE:
740
ADDRESS:8513 YELLOWTAIL WAYTELEPHONE:
(916) 725-2445
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 3DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ruby Liu, AdministratorTIME COMPLETED:
03:00 PM
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On 8/16/2022 Licensing Program Analyst (LPA) Jacob Williams arrived unannounced to conduct an annual inspection visit. LPA met with Administrator Ruby Liu and explained the purpose of the inspection. Prior to initiating the inspection, LPA completed required COVID-19 testing protocol, daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA toured the facility inside and out including but not limited to living room, dining room, kitchen, bathrooms, resident rooms & outside areas. Facility has enough paper and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 30 days. Facility has enough 2-day perishable and 7-day non-perishable food supply. Signage is posted throughout the facility.

While in facility, LPA also conducted investigation for a separate complaint matter.

LPA and staff reviewed and completed the infection control domain. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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