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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002804
Report Date: 10/13/2021
Date Signed: 10/13/2021 11:33:37 AM

Document Has Been Signed on 10/13/2021 11:33 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ODYSSEY LIFE CENTERFACILITY NUMBER:
345002804
ADMINISTRATOR:PENMAN, SHELBYFACILITY TYPE:
775
ADDRESS:283 IRON POINT RD UNIT ATELEPHONE:
(916) 988-0258
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 30CENSUS: 24DATE:
10/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shelby PenmanTIME COMPLETED:
12:00 PM
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LPA Lusby arrived on Wednesday October 13, 2021 to conduct the prelicensing inspection. Prior to 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; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA completed the prelicensing inspection domain with Administrator Shelby. LPA toured the facility.

Component III was conducted with Administrator. LPA will notify CAB that the facility is ready for licensure.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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