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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002613
Report Date: 06/25/2021
Date Signed: 06/25/2021 03:37:48 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:SUMMERFIELD SENIOR LIVINGFACILITY NUMBER:
515002613
ADMINISTRATOR:GILDEA, CHANTELFACILITY TYPE:
740
ADDRESS:1224 PLUMAS STREETTELEPHONE:
(530) 755-3850
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:99CENSUS: 59DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Celeste Tavares, Health and Wellness DirectorTIME COMPLETED:
03:47 PM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 06/25/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Celeste Tavares, Health and Wellness Director (HWD), and explained the purpose of the visit. Prior to initiating the annual inspection 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 and spoke to HWD, 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. Additionally, LPA was screened by Receptionist.

LPA and HWD toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, a couple of resident bedrooms, common bathrooms, memory care, assisted living, and PPE supplies.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and HWD completed the infection control domain and facility was found to be in substantial compliance at this time.

Several 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.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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