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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581372346
Report Date: 11/30/2021
Date Signed: 11/30/2021 02:14:44 PM

Document Has Been Signed on 11/30/2021 02:14 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:COMMUNITY RESOURCE SERVICES #4FACILITY NUMBER:
581372346
ADMINISTRATOR:COURTNEY, JESSICAFACILITY TYPE:
775
ADDRESS:814 6TH STREETTELEPHONE:
(530) 742-7610
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 15CENSUS: 5DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kira ParksTIME COMPLETED:
03:07 PM
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On 11/30/2021 1:30 PM 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) Kira Parks 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 AD 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/'staff person. 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, bathroom, isolation room, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA 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.
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: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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