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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002823
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:49:42 PM


Document Has Been Signed on 10/13/2022 03:49 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:WHOLESOME ELDERLY ON KIFISIAFACILITY NUMBER:
345002823
ADMINISTRATOR:FAAMUSILI, CHRISFACILITY TYPE:
740
ADDRESS:6024 KIFISIA WAYTELEPHONE:
(916) 678-0268
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Chris Faamusili, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 10/13/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Chris Faamusili, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 6 bedrooms and 2 bathrooms for residents, common area, dining room, kitchen, outdoor area, and storage. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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