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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295002148
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:20:17 PM

Document Has Been Signed on 06/23/2022 03:20 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:LAKE WILDWOOD MANORFACILITY NUMBER:
295002148
ADMINISTRATOR:LOVE, MARY VBFACILITY TYPE:
740
ADDRESS:17802 SILVER PINE DRIVETELEPHONE:
(530) 432-7788
CITY:PENN VALLEYSTATE: CAZIP CODE:
95946
CAPACITY: 6CENSUS: 2DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mary V Love, AdministratorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 6/23/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Mary V Love, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA toured the facility to ensure the health and safety of the residents in care. Areas toured include but are not limited to: 4 bedrooms and 2 bathrooms for residents, common area, dining room, food supply, laundry room, garage, storage 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.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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