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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001444
Report Date: 08/15/2022
Date Signed: 08/15/2022 12:28:36 PM

Document Has Been Signed on 08/15/2022 12:28 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:HIDDEN LAKE CARE HOMEFACILITY NUMBER:
315001444
ADMINISTRATOR:COPACIU, LYDIAFACILITY TYPE:
740
ADDRESS:8405 ACORN DRIVETELEPHONE:
(916) 791-2596
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY: 6CENSUS: 3DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Lydia and Eugene CopaciuTIME COMPLETED:
01:00 PM
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LPA Parks arrived on Monday August 15, 2022 to conduct the annual inspection. Prior to the visit, 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA was screen prior to entry into the facility. LPA and Administrators Lydia and Eugene completed the infection control domain together and facility was found to be in substantial compliance at this time. LPA and Administrators toured facility together to ensure health and safety of residents in care.

LPA requested updated copies of LIC500, LIC610, and current liability insurance to be faxed to LPA by end of the month.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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