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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 12/16/2021
Date Signed: 12/16/2021 02:48:23 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:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:TINA PREWITTFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:45CENSUS: 43DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tina NewtonTIME COMPLETED:
02:45 PM
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LPAs Lusby and Bains arrived on Thursday December 16, 2021 to conduct the annual inspection. Prior to the visit, LPAs 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; LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA and Administrator completed the infection control domain together. Facility was found to be in substantial compliance.

LPAs, Administrator, and Maintenance Director completed a facility walk through. No health, safety, or personal rights violations were observed.

LPA requested the following updated forms to be faxed to the office: LIC500, LIC610E, LIC308, and a copy of the current Administrator's certificate.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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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