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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001248
Report Date: 03/30/2022
Date Signed: 03/30/2022 09:47:01 AM


Document Has Been Signed on 03/30/2022 09:47 AM - 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:WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CTR.FACILITY NUMBER:
455001248
ADMINISTRATOR:GOSTAS, DARIENFACILITY TYPE:
740
ADDRESS:191 CHURN CREEK ROADTELEPHONE:
(530) 242-0654
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:56CENSUS: 35DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Darien Gostas, AdministratorTIME COMPLETED:
10:00 AM
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On 03/30/2022 Licensing Program Analysts (LPAs) Misty Valencia and Shannon Diegoruelas, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Darien Gostas, Administrator and explained the purpose of the visit. 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 Facility Administrator Melissa Johnson 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, LPAs were screened at front reception.

LPAs and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Administrator 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 emailed to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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