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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002454
Report Date: 10/08/2022
Date Signed: 10/08/2022 03:33:20 PM

Document Has Been Signed on 10/08/2022 03:33 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:JOAQUIN HOMEFACILITY NUMBER:
455002454
ADMINISTRATOR:CAMPBELL, JENNIFERFACILITY TYPE:
735
ADDRESS:662 JOAQUIN AVENUETELEPHONE:
(530) 244-9025
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 2DATE:
10/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Scott Chalfant, CaregiverTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 10/8/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Caregiver, Scott Chalfant, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA spoke to the Administrator, Cameron Olson, by phone and Cameron stated that caregiver can sign report.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 4 bedrooms and 2 bathrooms for residents, common areas, kitchen, laundry room, garage, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Caregiver completed the infection control domain.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2022
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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