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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002346
Report Date: 08/15/2022
Date Signed: 08/15/2022 02:13:32 PM

Document Has Been Signed on 08/15/2022 02:13 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:NORTH RESIDENTIALFACILITY NUMBER:
455002346
ADMINISTRATOR:DAVIS, CINDYFACILITY TYPE:
735
ADDRESS:1290 MISTLETOE LANETELEPHONE:
(530) 605-0323
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 6CENSUS: 6DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Tim Watson, StaffTIME COMPLETED:
11:00 AM
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08/15/2022 8:45 am Licensing Program Analysts (LPA) Shannon Diegoruelas, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Tim Watson, Staff and explained the purpose of the visit. Prior to initiating the annual inspection, 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 contacted AD 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 Administrator assistant.

LPA and the staff toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two and half (2 1/2) bathrooms, six (6) resident rooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and the staff 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 today’s inspection.

Exit interview conducted and copy of report was emailed to Admin.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Shannon Diegoruelas
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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