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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002783
Report Date: 01/07/2022
Date Signed: 01/07/2022 11:57:39 AM

Document Has Been Signed on 01/07/2022 11:57 AM - It Cannot Be Edited

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:NICOLET HOME INCFACILITY NUMBER:
455002783
ADMINISTRATOR:OSTERMAN, RUSSELLFACILITY TYPE:
735
ADDRESS:2958 NICOLET LANETELEPHONE:
(530) 262-5002
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 6CENSUS: 4DATE:
01/07/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tyler Webb-Assistant Administrator
Angela Doss Administrator 		TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Avila, arrived at the facility unannounced on 01/07/2022 at 11AM to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Assistant Administrator Tyler Webb and administrator Angelia Doss and explained the purpose of the visit. Prior to initiating the 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: PAPR Additionally, LPA was screened by Caregiver on duty..

LPA and Administrator toured the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time.


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

Exit interview conducted and copy of report was e-mailed
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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