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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700783
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:33:05 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:7117 MAIN, LLCFACILITY NUMBER:
342700783
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7117 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gladys Gasta; AdministratorTIME COMPLETED:
03:30 PM
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On 10/14/21 at 2:00 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced required 1-year annual inspection and met with Administrator Gladys Gasta. Prior to initiating the visit, 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; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by Gasta.

LPA Cheng toured the facility inside and out including but not limited to facility front entrance, living room, bathrooms, kitchen area, outside area, outside resident bedrooms, and storage rooms. All passageways are free of obstruction. All staff were observed to be wearing surgical masks. Facility entrance is equipped with proper COVID-19 signage and screening station. Facility has a mitigation plan in place should a COVID positive case occur. Facility has sufficient supply of perishable food, non-perishable food, medication, and PPE.

LPA Cheng completed infection control domain and observed no issues or concerns. No deficiencies observed.

Exit interview conducted and a copy of report was provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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