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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003843
Report Date: 02/09/2022
Date Signed: 02/09/2022 05:18:05 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:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:23 PM
MET WITH:Elenora BerciTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Administrator, Elenora Berci and explained purpose of inspection. LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive COVID-19 diagnoses. LPA were screened per COVID-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA observed (6) residents in the common area. The facility has an approved mitigation plan.

LPA and Administrator toured the interior of the facility, including but not limited to: private resident rooms, common restrooms, kitchen, laundry room, outdoor storage, and common areas. LPA observed it to be clean and in good repair. LPA observed required postings throughout in the facility. LPA advised Administrator to post handwashing posters inside the restrooms. Inside temperature was observed to be 75* F. Fire extinguisher last serviced 9/3/2021. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed ample PPE and medication supply located in secured cabinets. LPA observed the Administrator Certificate to be current and up to date. In the areas toured, there are no immediate health, safety, or personal rights violations were observed. Sharps, Toxins and Medications were secured in locked cabinets. LPA and Administrator discussed vaccination documentation of visitors and the most recent PIN 22-07. LPA and Administrator completed the infection control domain together and facility was found to be in compliance at this time.

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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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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