515002949-1-4-2023-25-AS-KHIA-CMRQFG-20230104110757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 515002949
Report Date: 01/04/2023
Date Signed: 01/04/2023 11:08:04 AM

Document Has Been Signed on 01/04/2023 11:08 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	DELTA AT HOLLY OAKS		FACILITY NUMBER:	515002949
ADMINISTRATOR:	VINCELET, CRAIG		FACILITY TYPE:	735
ADDRESS:	1880 LIVE OAK BLVD		TELEPHONE:	(530) 618-5615
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95991
CAPACITY: 70		CENSUS: 28	DATE:	01/04/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Melanie Byrd, Site Supervisor		TIME COMPLETED:	11:20 AM

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	LPA Hiratsuka conducted this unannounced prelicensing visit. LPA wore a surgical mask and observed all staff wearing them. LPA toured the facility with Site Supervisor Melanie Byrd. This facility is undergoing a change of ownership. It currently has residents in care. This facility has a fire clearance for 70 non-ambulatory residents. This facility has two buildings. The smaller building has 12 resident rooms that may be shared, a small laundry room and a room that has a sink and is going for storage. The rooms either have a private half-bathroom or some are set up where two rooms share a half-bathroom. There is a covered area that is between both buildings. The main entrance is in the main building. The main entrance opens to a foyer that has the medication room to the right and the dining and kitchen to the left. The first hallway to the left is going to have two offices, the laundry room, and a break room. The first hallway on the right are two large common rooms, a conference room, and another office. The main building currently has 23 resident rooms that are all going to be shared. The rooms either have a private half-bathroom or some are set up where two rooms share a half-bathroom. The hallway down the middle leads to a second hallway on the left and a second hallway on the right which are all shared resident rooms. There are two common half bathrooms in the middle hallway. There are two common shower rooms. Outside was inspected. There are two enclosed areas and one leads to the second building. The facility sketch submitted by the applicant does not match what the layout of the facility is. The facility sketch states some rooms are private and some are shared which does not add up to 70 residents. And the sketch does not show that two rooms on the left are going to be offices. LPA spoke to Site Supervisor and she indicated all resident rooms are going to be shared, which matches the capacity requested and the fire clearance that was granted.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: DELTA AT HOLLY OAKS	FACILITY NUMBER: 515002949
	VISIT DATE: 01/04/2023

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The only correction required is the applicant shall submit a new facility sketch for the main building that shows all resident rooms have double occupancy and the two offices in the first hallway on the left. Applicant shall submit that to the application specialist.

Component III orientation was conducted with Site Supervisor.

This facility does meet regulations and LPA is going to submit this report to the application specialist.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC809 (FAS) - (06/04)

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