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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000960
Report Date: 10/11/2021
Date Signed: 10/11/2021 08:13:13 AM

Document Has Been Signed on 10/11/2021 08:13 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:COMMUNITY RESOURCE SERVICES #5FACILITY NUMBER:
515000960
ADMINISTRATOR:KOLL, GAILFACILITY TYPE:
775
ADDRESS:732 PLUMAS STREETTELEPHONE:
(530) 751-2026
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 49CENSUS: 47DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Donna WinnenTIME COMPLETED:
08:15 AM
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10/11/2021 7:00 AM Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Assistant Coordinator (AC) Donna Winnen 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. LPA 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: N95. Additionally, LPA Keane was screened by AC.

LPA Keane and AC toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the AC 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 today’s inspection.

Exit interview conducted and copy of report was emailed to AC.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Dawn Keane
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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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