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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004674
Report Date: 12/22/2022
Date Signed: 12/22/2022 09:26:08 AM

Document Has Been Signed on 12/22/2022 09:26 AM - 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:JJ MOLINA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
347004674
ADMINISTRATOR:MOLINA, JOYFACILITY TYPE:
735
ADDRESS:4801 KENMAR ROADTELEPHONE:
(916) 913-1204
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 4CENSUS: 1DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Joy Molina, AdministratorTIME COMPLETED:
09:30 AM
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On December 22, 2022, at 8:30pm, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required Annual Inspection. LPA met Joy Molina and informed her the reason for the inspection. Prior to initiating the 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 completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore a mask for Personal Protective Equipment (PPE).

Joy and LPA completed the inspection tool questionnaire with no issues or advisories to report.

LPA observed the following:
Administrators Certificate is valid expiring 8/17/2023. First Aid Kit was complete and ready for emergency use. Fire extinguishers fully charged. Smoke detector and Carbon Monoxide detector are functional. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Common areas were clean and in good repair. Bedrooms had the required lighting and furniture. Bathrooms were clean.. Medications were properly stored and locked away.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than January 22, 2023.

An exit interview was conducted and a copy of this report was given to Joy.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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