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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002844
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:01:55 PM

Document Has Been Signed on 02/02/2023 03:01 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:COUNTRY SIDE HOME CAREFACILITY NUMBER:
315002844
ADMINISTRATOR:CERVANTES, SUSANFACILITY TYPE:
740
ADDRESS:2255 CENTRAL AVETELEPHONE:
(916) 789-1875
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 3DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Susan Cervantes, AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Susan Cervantes during today's inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 3 resident rooms, bathrooms, kitchen, common living spaces, outdoor space, and garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. Administrator stated there are no positive COVID case at the facility, and facility has sufficient amount of PPE. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. 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 as a result of todays inspection.

Exit interview conducted and copy of report left at the facility
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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