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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700785
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:45:08 PM

Document Has Been Signed on 11/08/2021 04:45 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:7125 MAIN, LLCFACILITY NUMBER:
342700785
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7125 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 0DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Margaret Agengo, CaregiverTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 11/8/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA contacted Administrator, Robert Coleman, via telephone, who permitted caregiver to sign report. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted the facility to complete a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

The facility currently has no residents.

LPA toured the facility. Areas toured include but are not limited to: 6 bedrooms and 2 bathrooms for residents, common area, dining room, kitchen, outdoor area, and laundry room. In the areas toured no immediate health, safety, or personal rights violations were observed. 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. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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