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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:24:51 PM

Document Has Been Signed on 09/02/2021 04:24 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 5DATE:
09/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Gladys Gasta, staffTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 09/02/2021 to conduct a case management visit regarding an eviction notice that LPA received on 08/31/2021 from facility. LPA met with staff Gladys Gasta and explained the purpose of the visit. Prior to initiating 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 they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

Eviction notice received was dated 08/09/2021 and issued to resident (R1) and their responsible party. Community Care Licensing (CCL) did not receive a copy of the eviction within five (5) days as required by Title 22 Regulations, therefore eviction is invalid and needs to be reissued. Additionally, a deficiency is being cited on the attached LIC 809-D. Staff informed LPA that R1 moved from the facility on 08/29/2021.

Exit interview conducted, appeal rights provided, and copy of report left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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Document Has Been Signed on 09/02/2021 04:24 PM - It Cannot Be Edited


Created By: Danyle Wolter On 09/02/2021 at 04:03 PM
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: 7121 MAIN, LLC
FACILITY NUMBER: 342700782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2021
Section Cited
CCR
87224(f)

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87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days.
This requirement was not met as evidenced by: documentation reviewed. The licensee did not comply with the regulation cited above. An eviction was issued to a resident and not sent to Community Care Licensing (CCL) within
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Licensee to review regulation 87224 and send letter of understanding regarding eviction procedures. Proof of correction due to CCL by 09/09/2021.
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five (5) days as required. This poses a potential health, safety, and/or personal rights risk 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:Laura Munoz
LICENSING EVALUATOR NAME:Danyle Wolter
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
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