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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000486
Report Date: 08/27/2021
Date Signed: 08/27/2021 10:07:52 AM

Document Has Been Signed on 08/27/2021 10:07 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CHESTNUT COMMONSFACILITY NUMBER:
515000486
ADMINISTRATOR:LISTA-THOMAS,LAURIEFACILITY TYPE:
735
ADDRESS:911 CHESTNUT ST. STE. ATELEPHONE:
(530) 674-3482
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 15CENSUS: 14DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:LISTA-THOMAS,LAURIE, AdministratorTIME COMPLETED:
10:30 AM
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8/27/2021 9:30 AM Licensing Program Analysts (LPAs) Misty Valencia and Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with Administrator Laurie Lista-Thomas and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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; contacted Administrator and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally LPAs were screened by Administrator.


LPAs Valencia, Keane and and Ms. Lista-Thomas toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, Three (3) resident apartments, three (3) bathrooms, kitchens, storage areas, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs Valencia, Keane and Lista-Thomas 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 emailed to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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