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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002938
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:02:02 AM


Document Has Been Signed on 12/01/2022 11:02 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:COZY HOME CAREFACILITY NUMBER:
345002938
ADMINISTRATOR:BRIONES, AIDA R.FACILITY TYPE:
740
ADDRESS:5643 CLARK AVE.TELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
12/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Aida BrionesTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Cassie Yang arrived announced at the facility on 12/01/2022 to conduct a Pre-licensing inspection. LPA met with Licensee, Aida Briones, and explained the purpose of the visit. Prior to initiating the inspection, 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 and contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Licensee upon entering the facility.

LPA and Licensee toured the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but are not limited to: common areas, resident bedrooms, bathrooms, laundry room, staff room and kitchen. LPA observed toxic, sharps and medications to be locked and secured. LPA observed the fire extinguisher to be last serviced 3/7/2022. LPA observed bathrooms to have soap, hand washing sign, trash can with lid, and paper towels in all shared bathrooms. LPA observed the exterior of the facility to have a clear pathway. Facility observed to have at least 2+ days of perishable and 7+ days of non-perishable foods. LPA observed the facility to have a working carbon monoxide detector, and smoke detectors located in all rooms. LPA advised Licensee staff door should have a lock to prevent residents from entering the room.

During this visit, deficiencies were observed. LPA informed Licensee fire doors cannot be opened with door stoppers. Licensee corrected the deficiencies immediately.

Pre-licensing inspection completed, Licensee waived Comp III as she is the Licensee at another RCFE.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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