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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581370929
Report Date: 02/24/2022
Date Signed: 02/24/2022 11:25:57 AM

Document Has Been Signed on 02/24/2022 11:25 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:COMMUNITY RESOURCE SERVICES #3FACILITY NUMBER:
581370929
ADMINISTRATOR:MILLS, DOMINIQUEFACILITY TYPE:
775
ADDRESS:1020 F STREETTELEPHONE:
(530) 742-0420
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 26CENSUS: 13DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Donna Mallett, StaffTIME COMPLETED:
11:30 AM
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On today's date around 10:15am, Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Donna Mallet, staff. LPA 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. In addition, Staff screened LPA prior to entering the facility.

LPA toured facility with staff to ensure health and safety of clients in care. Areas toured include but are not limited to: 2 activity rooms, staff office, kitchen, storage cabinets, and isolation room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Staff completed the infection control domain and facility was found to be in substantial compliance at this time.

During the inspection, LPA and staff discussed the facility's screening process, posting of posters, isolation room set-up, N95 Fit Testing, social distancing in the facility, and vaccination/boosters requirements for staff.

LPA advised staff to review Mitigation Plan and keep an updated one readily available at the facility.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of this report was left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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