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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005443
Report Date: 12/10/2021
Date Signed: 12/10/2021 10:26:04 AM

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:WINDING WAY VILLA, LLC.FACILITY NUMBER:
347005443
ADMINISTRATOR:STROUP, JENNIFERFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 671-3278
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
12/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jessica AdamsTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced Case Management visit and met with House Manager. LPA's 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by staff upon entering the facility.

The purpose of LPA's visit was to delivering an Order To Licensee/ Facility of Immediate Exclusion from all facilities. LPA delivered notice of "Immediate Exclusion" to House manager, Jessica Adams and explained the "Immediate Exclusion" notice indicating that prior employee, Kamethia Edwards cannot be allowed to work, be present and/or live in a CCL licensed facility and have contact with clients in any residential facility or child day care licensed by the California Department of Social Services.

No deficiencies were cited as a result of this visit.

A copy of this report was provided to administrator. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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