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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002559
Report Date: 11/30/2022
Date Signed: 11/30/2022 03:20:39 PM

Document Has Been Signed on 11/30/2022 03:20 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:OAK MESA HOMEFACILITY NUMBER:
455002559
ADMINISTRATOR:BAUGHMAN, LINDSAYFACILITY TYPE:
735
ADDRESS:1870 OAK MESATELEPHONE:
(530) 215-3973
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 4DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tavarius Simmons, Direct Care StaffTIME COMPLETED:
03:45 PM
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11/30/2022 Licensing Program Analyst (LPA) Shannon Diegoruelas, arrived at the facility
unannounced to conduct a Required-1 Year Inspection utilizing the infection control
domain. LPA met with Tavarius Simmons, Direct Care Staff and explained the purpose of
the visit. Prior to initiating the infection control annual inspection, LPA completed required
COVID-19 daily self-screening for symptoms of COVID-19 infection to affirm no
COVID-19 related symptoms. LPA contacted facility 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 facility staff.

LPA and the direct care staff toured facility to ensure health and safety of residents in
care. Areas toured include but are not limited to: outdoor area, common areas, three (3)
bathrooms, four (4) resident rooms, kitchen, and storage areas. In the areas toured no
immediate health, safety, or personal rights violations were observed. LPA and the direct
care staff completed the infection control domain and facility was found to be in
substantial compliance currently.

No deficiencies are being cited because of today’s inspection.

Exit interview conducted and copy of report was provided to Administrator
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Shannon Diegoruelas
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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