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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002972
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:39:44 PM

Document Has Been Signed on 01/18/2023 01:39 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:GOOD SAMARITAN CARE FACILITYFACILITY NUMBER:
345002972
ADMINISTRATOR:DANIELYAN, DANIELFACILITY TYPE:
740
ADDRESS:4406 BARRETT ROADTELEPHONE:
(916) 934-3909
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 0DATE:
01/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Hovhannes and Tadevos DanielyanTIME COMPLETED:
01:55 PM
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On January 18, 2023, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a prelicensing inspection. LPA met with Directors: Hovhannes Danielyan and Tadevos Danielyan and explained the purpose of the visit. The facility has (0) residents at this time.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) resident bedrooms in the first floor, and four (4) rooms located one the second floor for staff. The facility has a fire clearance for 6 ambulatory residents in Room 1-5. Room #1 is approved for one (1) ambulatory, room #2 is approved for one (1) ambulatory, room #3 is approved for two (2) ambulatory, room #4 is approved for one (1) ambulatory and room #5 is approved for one (1) ambulatory resident. LPA observed Administrator Certificate #6063121740 to be active on CCLD website. LPA observed the facility to have two garages.

LPA advised the facility to reverse the locks in the garage so residents cannot access the items in the garage such as detergents and/or gardening tools. LPA advised the facility to have the certificate posted on the wall. LPA advised the facility to post hand washing signs in the bathroom. LPA advised facility to have personal protective equipment such as surgical mask and hand sanitizers to be stationed throughout the facility.

LPA and Directors toured the second floor and checked the kitchen area for the ability to prepare and store food. LPA observed the space for medication, toxics and sharps to have locks. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishable foods.

During today's visit, LPA and Directors discussed the eviction regulation. LPA provided a copy of the regulation to Directors. Deficiencies were observed but corrected at the time of visit. Comp III has been completed.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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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