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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005726
Report Date: 05/27/2021
Date Signed: 05/27/2021 03:53:08 PM

Document Has Been Signed on 05/27/2021 03:53 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:WHISPERING PINE IIFACILITY NUMBER:
097005726
ADMINISTRATOR:SEREDA, IRINAFACILITY TYPE:
740
ADDRESS:923 APERO PLACETELEPHONE:
(916) 293-8598
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 6DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Irina Sereda, administratorTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 05/27/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator, Irina Sereda 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 and contacted licensee 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: N-95 Mask. Additionally, LPA was screened by administrator upon entry.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, brief inspection of six (6) resident bedrooms, shared resident bathroom, garage, laundry area, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain together 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 left at the facility.

Administrator to send in updated copy of LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, LIC 808 - Mitigation Plan, and current copy of Liability Insurance to Community Care Licensing by 06/03/2021.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
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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