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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003825
Report Date: 10/18/2022
Date Signed: 10/18/2022 04:01:44 PM


Document Has Been Signed on 10/18/2022 04:01 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:COZY HOME CAREFACILITY NUMBER:
347003825
ADMINISTRATOR:AIDA BRIONESFACILITY TYPE:
740
ADDRESS:5643 CLARK AVENUETELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Khanika MoodieTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on 10/18/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Staff contacted Administrator, who informed LPA she cannot make it to the facility until 40 minutes. Administrator stated caregiver can conduct an inspection with LPA. Prior to initiating the annual 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 facility staff upon entering the facility. LPA observed caregivers to be in compliance with mask.

Caregiver confirmed the facility currently has (5) residents and (1) resident on hospice services, in compliance to the facility license. LPA toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA confirmed both caregivers are associated on Guardian. LPA observed toxics, sharps and medications to be locked and secured. LPA observed the Administrator Certificate to be current. LPA observed the fire extinguisher to be last serviced 3/7/2022. LPA advised that facility put paper towels in all shared bathrooms. LPA and staff completed the infection control inspection and facility was found to be in substantial compliance at this time.

LPA requested a copy of the LIC 308, LIC 500, Administrator Certificate and current liability insurance to be emailed to LPA Yang by Tuesday October 25, 2022.

No deficiencies are being cited as a result of today's inspection.

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: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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