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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001553
Report Date: 05/05/2022
Date Signed: 05/05/2022 06:07:20 PM

Document Has Been Signed on 05/05/2022 06:07 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:AN OSPREY RETREATFACILITY NUMBER:
455001553
ADMINISTRATOR:HARONG, MENDILLAFACILITY TYPE:
740
ADDRESS:2154 OSPREY LNTELEPHONE:
(530) 224-1168
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 4DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:09 PM
MET WITH:Amanda Ambord, Direct Care StaffTIME COMPLETED:
05:10 PM
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Licensing Program Analysts (LPAs) Misty Valencia and Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Amanda Ambord, Direct Care Staff DCS 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; contacted administrator 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. Additionally, LPAs were screened by Amber at the front door.

LPAs and DCS toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, two (2) bathrooms, kitchen, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and the DCS completed the infection control domain 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 was given to administrator
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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