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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002613
Report Date: 06/03/2022
Date Signed: 06/03/2022 04:16:08 PM


Document Has Been Signed on 06/03/2022 04:16 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: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: 65DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Chantel GildeaTIME COMPLETED:
02:30 PM
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On 6/3/2022 LPA Tryon visited the facility to conduct an annual visit using the Infection Control Domain of the CARES Tool. LPA had self-screened prior to the visit, used hand sanitizer before entry, wore a surgical mask. Staff took LPA's temperature at the door and screened for COVID symptoms.

LPA met with Executive Director Chantel Gildea. Ms. Gildea took LPA on a tour of the facility including dining area, kitchen, supplies, resident rooms, bathrooms, memory care unit, laundry rooms, medication rooms and locked medication storage; supplies including supplies of PPE. We also toured hallways and common rooms/areas.

At this time the facility appears to be clean, well-furnished and in good condition. The facility has a good supply of perishable and non-perishable food. PPE supply looks to be adequate.

LPA reviewed the Infection Control Domain of the CARES Tool with Ms. Gildea.

At this time, the facility appears to be in substantial compliance with the regulations and COVID policies and protocols.

No deficiencies were noted at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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