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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002729
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:42:59 PM

Document Has Been Signed on 10/13/2022 02:42 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:CLOVERFACILITY NUMBER:
455002729
ADMINISTRATOR:SCHWARTZ, HEATHERFACILITY TYPE:
735
ADDRESS:19625 CLOVER ROADTELEPHONE:
(530) 782-2572
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Annie Lawrence and Colton Peterson Direct Support ProfessionalsTIME COMPLETED:
03:00 PM
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10/13/2022 Licensing Program Analyst (LPA) Shannon Diegoruelas, arrived at the facility unannounced to conduct a Health & Safety Inspection for a water well that has went dry. LPA met with Annie Lawrence and Colton Peterson Direct Support Professionals and explained the purpose of the visit. Prior to initiating the Heath and Safety 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 staff toured facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: laundry room with Mount Shasta Spring water that is being delivered in in 5 gallon containers, two (2) bathrooms with flushing water for toilets, kitchen with potable water for hand washing, garage with 1600 gallon water tank with water being delivered and proper plumbing to facility, and an out door area with a porta potty. Met with 2 residents who said they were overall good. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA found facility 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 provided to the Administrator and Licensee.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Shannon Diegoruelas
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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