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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803794
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:13:08 PM

Document Has Been Signed on 11/05/2021 01:13 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CHICO'S HOMEFACILITY NUMBER:
486803794
ADMINISTRATOR:MORALES, CECILIAFACILITY TYPE:
735
ADDRESS:832 WORLEY RDTELEPHONE:
(707) 688-5075
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 4CENSUS: 3DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Ceclia MoralesTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA), Katrina Walters arrived unannounced to conduct an Annual inspection at approximately 10:30 AM, and met with Licensee, Ceclia Morales. LPA conducted a risk assessment prior to entering the facility. The inspection is focused on the Infection Control procedures and practices of this facility. There were one staff providing care and supervision for two clients.

Upon entry, LPA was not screened for COVID-19 symptoms, Alcohol based hand wash and disposable mask was available for visitors and all staff were wearing mask. LPA conducted a walk through of facility with Administrator and made the following observations: Facility had required postings visible for visitors. Administrator understands that additional posters will need to be posted in the bathroom to promote hand washing and social distancing. Bathrooms were stocked with antibacterial hand soap and paper towel.

Staff are trained on Personal Protective Equipment (PPE), and infection control. Facility has 30+ day supply of PPE, and incontinence supplies. Facility is cleaned daily and high touch surfaces are cleaned each shift and after every meal. Facility was a comfortable temperature and exits were free from obstructions. All auditory alarms on exit doors, Facility smoke detectors and carbon monoxide detectors were found to be functioning properly at the time of the visit. There was a sufficient supply for both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations. This facility has not submitted a mitigation plan as of 11/05/2021. Administrator will submit mitigation plan by 11/08/2021.

No deficiencies observed or cited during today's Required 1- Year inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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