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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002442
Report Date: 06/22/2022
Date Signed: 06/23/2022 12:33:07 PM


Document Has Been Signed on 06/23/2022 12:33 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/23/2022 08:21 AM

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

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 ***AMENDED***


This report was amended due to FAS crashing on LPA during visit,

On 06/22/2022 Licensing Program Analyst (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrators Shaun and Saeed Hedayattzadeh, 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; contacted Facility Administrator Saeed Hedayattzadeh 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.

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 restrooms, and laundry area. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Administrator was not able to fully complete the infection control domain

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report emailed to Licensee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
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)
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