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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001241
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:24:00 PM

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:CEDAR GROVE CARE HOMEFACILITY NUMBER:
455001241
ADMINISTRATOR:DAVIS, ROBERTFACILITY TYPE:
740
ADDRESS:20233 BLUE JAY DRIVETELEPHONE:
(530) 223-9297
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 4DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gemma Davis; AdministratorTIME COMPLETED:
04:30 PM
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On 9/9/21 at 3 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced required 1-year annual inspection and met with Administrator Gemma Davis. Prior to initiating the visit, 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; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by staff.

LPA Cheng toured the facility inside and out including but not limited to facility kitchen, laundry room, outside area, resident bathrooms, living room, facility shower room, and resident rooms. All staff were observed to be wearing surgical masks. Facility entrance is equipped with proper COVID-19 signage and screening station. Facility has a mitigation plan in place should a COVID positive case occur. Facility has sufficient supply of perishable food, non-perishable food, medication, and PPE.

LPA Cheng completed infection control domain and observed no issues or concerns. LPA will e-mail additional infection control posters to add to existing ones in the facility.

Exit interview conducted and a copy of report was given.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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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