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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115002791
Report Date: 06/25/2022
Date Signed: 06/25/2022 01:21:31 PM

Document Has Been Signed on 06/25/2022 01:21 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:RIVERSIDE COUNTRY HOMEFACILITY NUMBER:
115002791
ADMINISTRATOR:TOEWS, MITCHELLFACILITY TYPE:
740
ADDRESS:8096 HIGHWAY 162TELEPHONE:
(530) 934-3686
CITY:GLENNSTATE: CAZIP CODE:
95943
CAPACITY: 6CENSUS: 3DATE:
06/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Roland D Loewen, administratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced on 06/25/2022 to conduct a Required 1 Year Inspection utilizing the infection control domain, LPA met with Roland Loewen (Administrator) 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, five (5) bathrooms, and kitchen. In the areas toured potential health, safety, or personal rights violations were observed. LPA and staff completed the infection control domain and Administrator was provided with technical advisories which will be corrected no later than July 1st, 2022. LPA will conduct a case management visit to ensure compliance.

LPA observed the fire extinguishers to be last serviced September of 2019. Administrator agreed to have them serviced annually and will have them serviced no later than July 1st, 2022.
LPA observed the resident records were incomplete and 2 of the 3 residents need updated LIC 602s. Administrator agrees to have this complete no later than July 8th, 2022.

LPA has requested the following documents to be provided to Community Care Licensing Department (CCLD) by COB 6/30/2022 via email and/ or fax(530) 895-5934.
Infection Control Plan
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 309 ADMINISTRATIVE ORGANIZATION
No citations issued. Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2022
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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