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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803794
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:40:30 PM

Document Has Been Signed on 11/04/2022 12:40 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
11/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Celia MoralesTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Walters arrived at the facility to conduct a case management visit. Administrator/Licensee arrived approximately 10 minutes after LPA arrived.

It was reported to Community Care Licensing that while at Day Program C1 was found to have had a loose pill in their backpack, that didn't belong to them. LPA conducted a record review and audit of 3 clients medications and log to ensure that the medication was not placed in C1's backpack by this adult residential facility.

The following determinations were made:Through record review LPA found that all of the medication for 3 of 3 clients were prescribed by a their physician and documented in their medication records. Medication was found to be in it's appropriate container, matching the description on the medication bottle. Medication appeared to be accounted for, and the medication found in C1's backpack did not match any of the 3 clients medications in the facility. LPA was unable to determine where the medication in C1's backpack came from.

Nothing further. No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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