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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 535002723
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:24:00 AM

Document Has Been Signed on 09/14/2022 11:24 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:SHASCADE TRINITY SERVICESFACILITY NUMBER:
535002723
ADMINISTRATOR:MARTIN, MELISSAFACILITY TYPE:
775
ADDRESS:171 MASONIC AVETELEPHONE:
(530) 623-6881
CITY:WEAVERVILLESTATE: CAZIP CODE:
96093
CAPACITY: 30CENSUS: 9DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Melissa Martin - administratorTIME COMPLETED:
12:00 PM
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09/13/2022 10:35 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with adminstrator Melissa Martin 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: N95 mask and gloves. Additionally, LPA was screened by facility staff.

LPA Knight, Ms. Martin toured the facility together to ensure health and safety of clients who attend program. Areas toured include but are not limited to: common areas, two (2) bathrooms, isolation room, and the kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight, Ms. Martin 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 emailed to Ms.Martin
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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