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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002569
Report Date: 02/11/2022
Date Signed: 02/11/2022 04:38:23 PM

Document Has Been Signed on 02/11/2022 04:38 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:GUANZON'S RESIDENTIAL CARE #3FACILITY NUMBER:
585002569
ADMINISTRATOR:GUANZON, LORENAFACILITY TYPE:
735
ADDRESS:5932 VINE COURTTELEPHONE:
(530) 741-0891
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Donnalyn Sayago, Care staff and Lorena Guanzon, AdministratorTIME COMPLETED:
04:45 PM
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On today's date around 3:25pm 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 Donnalyn Sayago, Care staff and Lorena Guanzon, Administrator. 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 Administrator and Staff to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, bathroom, bedrooms, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

During the inspection, LPA requested for a copy of LIC 500 and a copy of Administrator Certificate be submitted to Licensing. An updated emergency disaster plan was submitted to Licensing on 1/27/2022.

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: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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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