<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002267
Report Date: 06/22/2022
Date Signed: 06/22/2022 03:30:38 PM

Document Has Been Signed on 06/22/2022 03:30 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:MONIKA'S RESIDENTIAL CAREFACILITY NUMBER:
455002267
ADMINISTRATOR:NORA BENTEFACILITY TYPE:
735
ADDRESS:1391 DENTON WAYTELEPHONE:
(530) 222-2149
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 6CENSUS: 5DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Administrator Nora BenteTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/22/2022 Licensing Program Analyst (LPA) Misty Valencia, arrived at the facility unannounced on 07/08/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator Nora Bente, and explained the purpose of the visit. Prior to initiating the annual inspection 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. LPA attempted to contact Facility Representative to complete a facility risk assessment, but was unable to. LPA did do a risk assessment upon arrival. 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 at the back door before entering facility.

LPA and Administrator toured facility together to ensure health and safety of the facility. Areas toured include but are not limited to: common areas, resident bedrooms, common restroom and laundry area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and House Manager 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 left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1