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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001241
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:51:51 PM


Document Has Been Signed on 11/16/2022 03:51 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: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:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lydia Aguilar, CaregiverTIME COMPLETED:
04:00 PM
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11/16/2022 Licensing Program Analyst (LPA) Shannon Diegoruelas, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Lydia Aguilar, Caregiver and explained the purpose of the visit. Prior to initiating the infection control annual inspection, LPA completed required COVID-19 daily self-screening for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted facility 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. Additionally, LPA was screened by facility staff.

LPA and the caregiver toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: Outdoor area, common areas, eight (8) bathrooms, six (6) resident rooms, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and the administrator completed the infection control domain and facility was found to be in substantial compliance currently.



No deficiencies are being cited because of today’s inspection.

Exit interview conducted and copy of report was provided to Administrator
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Shannon DiegoruelasTELEPHONE: (530) 282-2393
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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