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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 06/24/2021
Date Signed: 06/24/2021 04:26:56 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:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 4DATE:
06/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Gladys Gasta, administratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 06/24/2021 to conduct a case management visit, LPA met with administrator Gladys Gasta and explained the purpose of the visit. Prior to initiating the case management, 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, LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

Community Care Licensing (CCL) received an incident report on 06/21/2021 regarding an incident with resident (R1) on 06/19/2021. R1 was observed to be shaking while sitting in their wheelchair which is not their baseline, emergency services were called and R1 was treated by paramedics, paramedics contacted R1's responsible party and it was decided that R1 did not need to be transported at that time.

Administrator informed LPA that R1 had another incident on 06/23/2021- incident report to follow, and that home health is being ordered for the resident. Administrator stated that a new care plan will be created with home health's recommendations and R1 has increased observation checks at this time.

No deficiencies are being cited as a result of today's inspection.
Exit interview conducted and copy of report to be sent to administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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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