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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001963
Report Date: 08/20/2021
Date Signed: 08/20/2021 04:22:08 PM

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:WILLOW GLEN CARE CENTERFACILITY NUMBER:
515001963
ADMINISTRATOR:GILBERT, DAVIDFACILITY TYPE:
740
ADDRESS:1547 PLUMAS COURTTELEPHONE:
(530) 751-9900
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:60CENSUS: 59DATE:
08/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Angie Karris; AdministratorTIME COMPLETED:
04:40 PM
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On 8/20/21 at 12 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Health and Safety visit and met with Administrator Angie Karris. Prior to initiating the visit, 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: surgical mask and gloves. Additionally, LPA was screened by staff.

The purpose of LPA's visit today was to conduct a Health and Safety check on six clients who was relocated from Alpine House due to an evacuation order issued by Trinity County. LPA toured the facility inside and out including but not limited to facility activity area, hallways, both wings of the facility, dining area, and medication room. Alpine client's medications are centrally stored in a separate locked container from Willow Glen's client medications. All of Alpine client's Medication Administration Record and Centrally Stored Medication Log is kept separate from Willow Glen's client records. Facility is following their COVID-19 procedures and have an isolation plan in place should any individual become positive. Facility has sufficient supply of food, toilet paper,and other necessities. Licensee of Willow Glen Care Center is also the Licensee of Alpine House.

No deficiencies or concerns noted.

Exit interview conducted and a copy of the report was given.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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