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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002837
Report Date: 12/02/2022
Date Signed: 12/02/2022 11:04:35 AM

Document Has Been Signed on 12/02/2022 11:04 AM - 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:CROWN POINT VILLAFACILITY NUMBER:
315002837
ADMINISTRATOR:MUBEEZI, VIOLETFACILITY TYPE:
740
ADDRESS:1001 TAMARACK COURTTELEPHONE:
(301) 541-4028
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 4DATE:
12/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator- Violet Mubeezi TIME COMPLETED:
11:30 AM
NARRATIVE
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On 12/02/2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced and met with Administrator, Violet Mubeezi, to conduct a Case Management visit. LPA wore Surgical mask and was screened by facility upon entry.

LPA observed a care staff that is not associated to the facility providing care and supervision to residents in care. LPA informed Administrator that staff cannot be present at the facility providing care and supervision until associated to the facility.

Deficiencies cited on LIC 809-D.

Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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Document Has Been Signed on 12/02/2022 11:04 AM - It Cannot Be Edited


Created By: Sarena Keosavang On 12/02/2022 at 09:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CROWN POINT VILLA
FACILITY NUMBER: 315002837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/02/2022
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department.
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Administrator agrees to have caregiver associated to the facility. Adminsitrator is to send into CCL their plan of ensuring all staff to be associated and fingerprint cleared.
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This requirement is not met as evidenced by: Based on observation, records review, and interviews, S1 is not associated to the facility on Guardidan and LIS. Administrator stated S1 has provided care and supervision to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022


LIC809 (FAS) - (06/04)
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