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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700785
Report Date: 11/22/2022
Date Signed: 11/22/2022 12:28:39 PM


Document Has Been Signed on 11/22/2022 12:28 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:7125 MAIN, LLCFACILITY NUMBER:
342700785
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7125 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 2DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Facility staff- Julene AndersonTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/22/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with facility staff, Julene Anderson and explained the purpose of the visit. LPA and staff called administrator over the phone who gave permission to do today's visit with staff -Julene Anderson since they are not able to come. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA confirmed that facility does not any positive covid-19 cases and nobody is experiencing any covid-19 symptoms today before facility entry. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by facility staff upon entry.


LPA and staff toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, dining area, residents bedrooms, 2 bathroom, laundry room and backyard area. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and staff completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today's inspection .
Exit interview conducted and copy of report left at the facility.



SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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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