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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004881
Report Date: 01/19/2022
Date Signed: 01/19/2022 12:28:14 PM

Document Has Been Signed on 01/19/2022 12:28 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ROSA CHICO'S CARE HOMEFACILITY NUMBER:
347004881
ADMINISTRATOR:CHICO, EVELYNFACILITY TYPE:
735
ADDRESS:8868 TIMM AVENUETELEPHONE:
(916) 390-8564
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 4DATE:
01/19/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Liwayway Chico- Facility Staff TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 1/19/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with facility staff, Liwayway Chico, and explained the purpose of the visit. 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 completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA requested for facility staff to notify Administrator that LPA is at the facility to conduct an annual inspection. Facility staff notified Administrator however Administrator is unable to meet LPA at the facility. Administrator gave staff permission to assist LPA and sign report.

LPA toured the interior and exterior of the facility together with facility staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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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