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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000981
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:32:51 PM


Document Has Been Signed on 03/22/2022 02:32 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:JIM & LIZA'S CARE HOMEFACILITY NUMBER:
455000981
ADMINISTRATOR:HOLDEN, MERLINDAFACILITY TYPE:
740
ADDRESS:4929 HUNTINGTON DRIVETELEPHONE:
(530) 221-0220
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 6DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marie Therese GaudTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPAs) Shannon Diegoruelas and Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Marie Therese Gaud Caregiver and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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; contacted the facility and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask and was screened at the front door.

LPAs and Ms. Gaud toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, two (2) bathrooms, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Ms. Gaud 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 was emailed to administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Shannon DiegoruelasTELEPHONE: (530) 282-2393
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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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