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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577001215
Report Date: 06/17/2022
Date Signed: 06/17/2022 03:34:58 PM


Document Has Been Signed on 06/17/2022 03:34 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:UNIVERSITY RETIREMENT COMMUNITY AT DAVISFACILITY NUMBER:
577001215
ADMINISTRATOR:MARIA BURTONFACILITY TYPE:
741
ADDRESS:1515 SHASTA DRIVETELEPHONE:
(530) 747-7000
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:500CENSUS: 48DATE:
06/17/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Cecilia Binamira, Director of NursingTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to meet with Administration of facility regarding the reporting of Covid-19 cases to Community Care Licensing. LPA arrived to review protocols for reporting Covid-19 cases. LPA was able to talk with the Director of Nursing in the SNF, who said they would help in reminding staff to call in with complete information (Name, date of test, date results were received, symptoms, and vaccination dates and type).

Facility was practicing Covid-19 protocols at the entrance to facility: with screening questions, temperature check, and mask requirement for entry.

There were no deficiencies found on this visit and no citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
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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