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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002608
Report Date: 06/23/2021
Date Signed: 06/23/2021 10:55:09 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
FACILITY NAME:SENIOR CARE ASSISTED LIVING INCFACILITY NUMBER:
455002608
ADMINISTRATOR:PEACOCK, CINDYFACILITY TYPE:
740
ADDRESS:2635 SAPPHIRE LANETELEPHONE:
(530) 378-5016
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:7CENSUS: 0DATE:
06/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kate Baker, LicenseeTIME COMPLETED:
11:00 AM
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6/23/2021 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight conducted an announced visit to the facility and met with Licensee Kate Baker and administrator Cindy Peacock.. Before entering the facility, LPA took their own temperature which registered within normal range. LPA Knight donned appropriate PPE in the following order: Performed hand hygiene, N-95 mask, and latex gloves.

The purpose of this visit was to determine whether or not there were any residents in care. In a letter dated 6/08/2021 which was received on 6/14/2021 at the Community Care Licensing Chico office, Mrs. Baker stated they planned to close the facility on 6/21/2021. Their last resident relocated on 6/22/2021.

Mrs. Baker invited LPA Knight into the facility and allowed LPA to tour the facility. LPA observed the facility to be empty with no residents in care.

LPA Knight collected the facility license during this visit.

No deficiencies were cited during this visit.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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