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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700416
Report Date: 11/18/2022
Date Signed: 11/18/2022 05:36:46 PM

Document Has Been Signed on 11/18/2022 05:36 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:ELDERLY INN IV, THEFACILITY NUMBER:
342700416
ADMINISTRATOR:TOPLEAN, SAMFACILITY TYPE:
740
ADDRESS:4908 ILLINOIS AVETELEPHONE:
(916) 844-7025
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 6DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sam Toplean, LicenseeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 11/18/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Licensee, Sam Toplean, and explained the purpose of the visit. LPA 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: 5 bedrooms and 4 bathrooms for residents, common areas, kitchen, outdoor area, laundry area, and PPE supplies. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee completed the infection control domain.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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