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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003723
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:49:46 PM

Document Has Been Signed on 02/22/2023 12:49 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:CHARIBEL JOSE CARE HOME, INC.FACILITY NUMBER:
347003723
ADMINISTRATOR:BALBUENA, EVELIOFACILITY TYPE:
735
ADDRESS:5831 TREE HILL CTTELEPHONE:
(916) 332-5277
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 4DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staff: Marcinette MarrettoTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 02/22/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff, Marcinette Marretto, 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: Surgical Mask. LPA requested for staff to notify administrator of LPA's presence at the facility to conduct an annual inspection. Administrator is unable to meet LPA at the facility.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 2 bedrooms and 2 bathrooms for residents, common area, activity room, dining room, food supply, garage, laundry room, PPE supply, outdoor area, and shed. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain via telephone and facility was found to be in substantial compliance at this time.

No deficiencies are being cited.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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