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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000486
Report Date: 07/28/2022
Date Signed: 07/28/2022 03:16:03 PM

Document Has Been Signed on 07/28/2022 03:16 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, 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:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amanda SchnepelTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct an Annual Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Caregiver. Administrator arrived during the visit.

LPA and Caregiver toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. Administrator finished the visit.


Multiple topics were discussed.


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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