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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001690
Report Date: 09/16/2021
Date Signed: 09/16/2021 05:20:32 PM

Document Has Been Signed on 09/16/2021 05:20 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:INTERMOUNTAIN DISABILITY SERVICESFACILITY NUMBER:
455001690
ADMINISTRATOR:JOHNSON, BRENDAFACILITY TYPE:
775
ADDRESS:37009 HWY 299ETELEPHONE:
(530) 335-2833
CITY:BURNEYSTATE: CAZIP CODE:
96013
CAPACITY: 30CENSUS: DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adminsitrator Brenda JohnsonTIME COMPLETED:
01:15 PM
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09/216/2021 12:00 PM Licensing Program Analysts (LPAs) Misty Valencia and Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Administrator Brenda Johnson 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 administrator 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: N-95 Mask, Additionally, LPAs was screened by staff at the front door.

LPAs, and Mrs Johnson toured the facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, isolation room, and the kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs, and Mrs. Johnson 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 Mrs. Johnson.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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