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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002807
Report Date: 10/27/2022
Date Signed: 11/01/2022 08:42:52 AM

Document Has Been Signed on 11/01/2022 08:42 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:IMAGINEFACILITY NUMBER:
525002807
ADMINISTRATOR:LEAK, TAMRAFACILITY TYPE:
735
ADDRESS:25347 LEE STTELEPHONE:
(530) 200-2909
CITY:LOS MOLINOSSTATE: CAZIP CODE:
96055
CAPACITY: 6CENSUS: 6DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:CaregiverTIME COMPLETED:
11:10 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
10/27/22 Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with caregiver Maria Vergen 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 completed a facility risk assessment upon arrival. 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 facility staff. Administrator was notified but was unable to attend.

LPA and Caregiver toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, three (3) bathrooms, kitchen, storage areas and office.
LPA advised that the facility sketch be updated to reflect that Rm 1 no longer has a second exit. Rm 1 was designated a non-ambulatory room. New sketch and updated LIC 200 will be submitted to the regional office. Additionally licensee will either replace the be hall fire alarm or get approval from Fire for it's removal.
LPA and the caregiver completed the infection control domain and facility was found to be in substantial compliance at this time. LPA advised fit testing of N-95s be completed for staff who may work with Covid Pos. clients

Deficiency is being cited as a result of todays inspection. Technical assistance also was provided.

Exit interview conducted and copy of report was emailed to Maria Vergen.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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