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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003843
Report Date: 09/03/2021
Date Signed: 09/03/2021 01:33:16 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:NORTH AVENUE VILLAFACILITY NUMBER:
347003843
ADMINISTRATOR:ADRIAN BERCIFACILITY TYPE:
740
ADDRESS:5216 NORTH AVENUETELEPHONE:
(916) 705-3729
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nora Berci, Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with caregiver, Tatleen Lewis, who screened LPA upon entering the community and contacted Nora Berci, Administrator who arrived at 12:30 pm. LPA explained purpose of inspection. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask There are (6) residents at the facility and (2) residents are currently receiving hospice services. LPA observed (1) additional staff, Eden Wright, present, and was wearing a mask, preparing lunch.

LPA observed (5) residents to be sitting in the dining room and (1) resident was in their room during the inspection. LPA and caregiver toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (6) resident bedrooms, (2) resident restrooms, kitchen, dining room. LPA and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 75* F. LPA's observed Covid posters in main entrance- will ensure hand hygiene poster is posted in each bathroom.

Resident and staffing vaccinations discussed as well as current requirements for weekly testing.

There were no deficiencies cited as a result of todays inspection.

Exit interview conducted with Administrator, and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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