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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 12:43:14 PM

Document Has Been Signed on 11/04/2022 12:43 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Celia MoralesTIME COMPLETED:
12:52 PM
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Licensing Program Analyst (LPA) Walters arrived at the Adult Residential Facility (ARF) unannounced to conduct Required- 1 Year visit. Administrator/Licensee, Celia Morales arrived approximately 10 minutes after LPA arrived. This inspection will focus on the infection control procedures this facility.

This facility is a single-story home with 5 bedrooms: 2 bedroom for staff and 3 bedroom for clients. There are currently 3 clients residing in this facility. In the event of an outbreak, the clients are able to maintain distancing in each room. The facility operates with 24 live-in hour staffing that provide care and supervision. During the inspection clients were attending day program elsewhere. At the entrance of the home, there is a table with sanitizer available for visitors.

The home was a comfortable temperature, clean and was observed to be in good repair. Per Administrator major surface areas are disinfected routinely. Fire extinguishers were charged, last serviced on 11/17/2022. All exits and walkways were found to be unobstructed and were free of debris. Smoke and carbon monoxide detectors were tested and found to be operational. There are emergency lights for clients in the hallway. LPA observed at least a 30 day supply of medication, incontinence products and personal protective equipment.

Medication given is documented in clients records, additionally vaccination records are stored in perspective client folders and easily accessible. Medication and records were locked in the cabinet in the living room and inaccessible to residents. Medications were organized and in good order. In the event that a client/staff are showing symptoms facility has procedures for testing for COVID -19. Bathrooms were stocked with hand washing supplies and paper products. Signs were posted in the bathroom to promote hand washing. No deficiencies cited during visit.
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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