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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700959
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:03:27 PM

Document Has Been Signed on 01/31/2023 12:03 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PALMS COURT IIFACILITY NUMBER:
312700959
ADMINISTRATOR:OGUNDIWIN, ADEOLAFACILITY TYPE:
740
ADDRESS:1419 CHAMPION OAKS DRTELEPHONE:
(559) 349-3057
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 5DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator- Adeola Ogundiwin TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 01/31/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met Administrator, Adeola Ogundiwin, and explained the purpose of the visit. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 6 bedrooms and 6 bathrooms for residents, common area, dining room, food supply, laundry room, outdoor area, and storage. 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.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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