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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000981
Report Date: 04/07/2022
Date Signed: 04/07/2022 04:50:14 PM

Document Has Been Signed on 04/07/2022 04:50 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: DATE:
04/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Merlinda Holden, LicenseeTIME COMPLETED:
05:15 PM
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04/07/2022 Licensing Program Analyst (LPA) Misty Valencia conducted a physical PCC visit with Merlinda Holden, Licensee, Zach Hale, Zach Crow PHD staff and CCL Nurse Helen Shi regarding infection control for current positive staff/residents in the facility.

Nurse SHi Made the following recommendations;
-wear N95 Masks during positives in the facility
-add washing direction signs around all sinks that indicate 20 seconds of hand washing.
-garbage cans with lids in all bathrooms as well as inside/outside front door.
-no hand towels, wash rags around kitchen area.
-PPE cart outside the front door and make facility a covid positive facility.

LPA and Licensee set up trash cans and PPE cart outside front door.

LPA will email Licensee Donning/Doffing sign to put inside/outside the front door. All staff who comes in will


An additional PCC televisit will not be required as a result of the newly reported Covid positives and the pending test results for all staff and residents even if they receive any more positive results.

Licensee reports that she will contact LPA with any questions or concerns.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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