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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002807
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:37:32 PM

Document Has Been Signed on 10/21/2021 01:37 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:IMAGINEFACILITY NUMBER:
525002807
ADMINISTRATOR:PHELPS, ASHLEYFACILITY TYPE:
735
ADDRESS:25347 LEE STTELEPHONE:
(530) 200-2909
CITY:LOS MOLINOSSTATE: CAZIP CODE:
96055
CAPACITY: 6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tamra Leak - adminstratorTIME COMPLETED:
02:00 PM
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10/21/2021 01:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct a Pre-Licensing visit. LPA met with administrator Tamra Leak and explained the purpose of the visit. Prior to initiating the annual inspection, 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask, gloves. Comp 3 was waived by administrator as this facility facility is currently licensed.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. The facility has six (6) bedrooms, 2 of which are cleared for non-ambulatory residents. The facility has two (2) bathrooms which were observed to be in good repair. LPA observed 1 dining table with 6 chairs in the dining room. LPA observed a couch, love seat and 2 recliners in the common area.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave and refrigerator were all present and working.

The facility has one fully charged fire extinguisher which was inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning.

Continued on LIC809-C

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: IMAGINE
FACILITY NUMBER: 525002807
VISIT DATE: 10/21/2021
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Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. The facility stores linens and towels in the staff room on shelves.

Storage and lighting is adequate in the home. Medications are locked up in a cabinet in the kitchen. Also locked in the kitchen are knives. Cleaning supplies and toxins are locked up in a cabinet in the kitchen and in a locked cupboard in the staff room. Laundry detergent is locked in a cabinet in the garage next to the washer and dryer. Washer and dryer observed in place.

The back yard has a covered porch with a table, and chairs for the clients to use.

The facility has Covid-19 preparations in place to include signs, proper cleaning protocols are in place. All staff were observed wearing masks while in the facility. The facility also has proper screening for all staff visitors and clients.

The applicant has passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

// Exit Interview and copy of report emailed to the administrator.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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