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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 535002723
Report Date: 09/27/2021
Date Signed: 09/27/2021 10:14:57 AM

Document Has Been Signed on 09/27/2021 10:14 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:SHASCADE TRINITY SERVICESFACILITY NUMBER:
535002723
ADMINISTRATOR:MARTIN, MELISSAFACILITY TYPE:
775
ADDRESS:171 MASONIC AVETELEPHONE:
(530) 623-6881
CITY:WEAVERVILLESTATE: CAZIP CODE:
96093
CAPACITY: 30CENSUS: DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Christine WadeTIME COMPLETED:
10:56 AM
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9/27/2021 9:30 AM Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain .LPA met with Instructor (IN) Christine Wade 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; contacted administrator Melissa Martin and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and
the following Personal Protective Equipment (PPE) was worn: N95. Additionally, LPA Keane was screened by IN. LPA Keane and IN toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathrooms, isolation room, and storage areas. In the
areas toured no immediate health, safety, or personal rights violations were observed. Keane and the IN completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Technical assistance was provided. Exit interview conducted and copy of report was given to IN
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Dawn Keane
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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