<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002617
Report Date: 05/16/2022
Date Signed: 05/16/2022 03:19:18 PM


Document Has Been Signed on 05/16/2022 03:19 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:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:CRAIG VINCELETFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:79CENSUS: 23DATE:
05/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Melanie Byrd, Site SupervisorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Mai Thao and Talwinder Bains arrived at the facility to conduct an unannounced case management visit. LPA met with Melanie Byrd, Site Supervisor. LPA explained the purpose of the visit. Prior to initiating the case management visit, LPAs 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. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. In addition, Staff screened LPAs prior to entering the facility.

On today's date, Licensing Program Analyst (LPAs) Mai Thao and Talwinder Bains arrived unannounced to the facility to conduct a case management visit. LPAs met with Melanie Byrd, Site Supervisor and explained purpose of visit is to clear Plan of Corrections from deficiency that was cited on 4/12/2022.

On 4/12/2022, during an annual inspection, the facility was cited CCR 87463(c). On 4/27/2022, the facility submitted POC documentation to Licensing that met the POC agreed upon.

During today's visit, LPA cleared the POC and provided the a copy of the POC clearance letter to Melanie Byrd, Site Suptervisor.

No citations were issued during today's visit. Exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1