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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000503
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:52:47 AM

Document Has Been Signed on 04/14/2022 10:52 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:PAUL AND LAURA HASE GUEST HOMEFACILITY NUMBER:
515000503
ADMINISTRATOR:HASE, LAURAFACILITY TYPE:
735
ADDRESS:2429 IVY STREETTELEPHONE:
(530) 695-3905
CITY:LIVE OAKSTATE: CAZIP CODE:
95953
CAPACITY: 3CENSUS: 3DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Laura Hase, AdministratorTIME COMPLETED:
11:00 AM
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On 4/14/2022 around 9:15am, Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator Laura Hase and explained the purpose of the visit. Prior to initiating the annual inspection, LPA 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA and Administrator toured the facility together to ensure health and safety of residents in care. During today's inspection, Licensee Paul Hase, Administrator Laura Hase, and 3 clients are at the facility. Due to COVID-19, 3 clients are only attending Day Porgram once a week for outside activities and volunteering. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, dining area, storage areas, and laundry room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and the administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

During today's inspection, LPA and Administrator also reviewed 3 of 3 client's P&I Cash. Around 9:40am, LPA and Administrator observed that the facility has a Sun Room added to the facility that is not on the facility sketch. LPA advised Licensee and Administrator on making alteration to the facility (CCR 80086) LIC forms that are needed. Licensee and Administrator stated that the alteration started in November 2021 and was completed in December 2021. Licensee and Administrator provided LPA with a copy of permits during the inspection. LPA requested for Licensee and Administrator to fax a copy of LIC 200 and floor plans to Licensing by close of business (COB) today.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report was left at the facility with Licensee and Administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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