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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005332
Report Date: 10/05/2022
Date Signed: 10/05/2022 03:56:20 PM


Document Has Been Signed on 10/05/2022 03:56 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:CHRISMAN COMMUNITYFACILITY NUMBER:
347005332
ADMINISTRATOR:CLAUDIA MIHAIFACILITY TYPE:
740
ADDRESS:4230 PARADISE DRIVETELEPHONE:
(916) 515-8590
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
10/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator, Claudia MihaiTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/5/2022, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced to conduct a case management inspection. LPA met with caregiver, Mauvette Henriques, and stated the reason for the inspection. Caregiver, Mauvette Henriques, contacted Administrator, Claudia Mihai by phone who arrived shortly to the facility.

LPA requested to review former resident (R1)'s file. LPA was informed that the facility does not have the file as a family member has retrieved the documents and have not return with the documents. Administrator informed LPA she was aware that the files cannot leave facility.

As a result of this visit, deficiency was observed and cited. Please see the attached LIC 809-D.

An exit interview was conducted and copy of report and appeal rights provided to Administrator.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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Document Has Been Signed on 10/05/2022 03:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: CHRISMAN COMMUNITY
FACILITY NUMBER: 347005332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2022
Section Cited

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87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by:
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Based on observation and record review of R1's file, the licensee did not comply with the section cited above that all resident records shall be kept and retained for minimum of 3 years which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
LIC809 (FAS) - (06/04)
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