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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803794
Report Date: 10/31/2023
Date Signed: 10/31/2023 09:07:50 AM

Document Has Been Signed on 10/31/2023 09:07 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, 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: 4DATE:
10/31/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Licensee, Cecilia MoralesTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Chico's Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Licensee, Cecilia Morales, and was granted access into the facility.

During this Case Management-Annual Continuation, LPA interviewed staff and clients in care. Emergency Disaster Plan was discussed. However, during the discussion of the Emergency Disaster Plan, LPA observed the facility sketch did not have assembly points (See LIC 9102-Technical Advisory). LPA educated the licensee on submitting a new Facility Sketch to include assembly points during an evacuation and updating the Emergency Disaster Plan (See LIC 9102-Technical Violation). During the review of the Infection Control Plan, LPA determined that the Infection Control Plan will need to be updated to reflect the most up-to-date Infection Control Regulations as specified in Title 22 regulations (See LIC 9102-Technical Violation). LPA educated the Licensee regarding this regulation and provided Technical Assistance during the course of the Case Management-Annual Continuation on the Infection Control requirements. LPA requested the following documents to be sent:
LIC 500-Personnel Report
LIC 308-Designation of Responsibility
Liability insurance
Control of Property
Client Roster
Staff Roster
Infection Control Plan
Updated Emergency Disaster Plan
Updated Facility Sketch to include Assembly Points
No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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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