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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005412
Report Date: 07/16/2021
Date Signed: 07/16/2021 11:36:04 AM

Document Has Been Signed on 07/16/2021 11:36 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:VIRGINIA DENISE COUNTRY HOMEFACILITY NUMBER:
347005412
ADMINISTRATOR:FERMO, AILEENFACILITY TYPE:
740
ADDRESS:2305 VIRGINIA DENISE LANETELEPHONE:
(916) 813-0460
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 4DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Aileen Fermo, administratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/16/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator Aileen Fermo 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 and contacted facility and completed a facility risk assessment.

LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, laundry room, garage, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and administrator completed the infection control domain together 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 facility.

Administrator to send in LIC 808 - Mitigation Plan and copy of current liability insurance to Community Care Licensing by 07/23/2021.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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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