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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700299
Report Date: 06/24/2021
Date Signed: 06/24/2021 10:47:00 AM

Document Has Been Signed on 06/24/2021 10:47 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HAPPY MEMORIES SENIOR CAREFACILITY NUMBER:
342700299
ADMINISTRATOR:CHIS, CARMENFACILITY TYPE:
740
ADDRESS:255 CIMMARON CIRCLETELEPHONE:
(707) 365-6353
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 6CENSUS: 5DATE:
06/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Soloman Chis (Admin)TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 6/24/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Solomon Chis and Carmen Chis (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection, 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and was sure to wear a Surgical Masks. Additionally, LPA was screened by Admin and documented in their visitor screening log.

LPA and admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) of six (6) resident bedrooms, two (2) of two (2) care giver rooms, three (3) of three (3) bathrooms, kitchen, office, laundry room, pantry, and storage areas and backyard. LPA viewed the facilities supply of PPE and food to be sufficient in quantity. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin 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: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
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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