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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570316115
Report Date: 06/16/2022
Date Signed: 06/16/2022 12:34:21 PM

Document Has Been Signed on 06/16/2022 12:34 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CALIFORNIAN, THEFACILITY NUMBER:
570316115
ADMINISTRATOR:KATHY B. NEESERFACILITY TYPE:
740
ADDRESS:1224 COTTONWOOD STREETTELEPHONE:
(530) 666-2433
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 130CENSUS: DATE:
06/16/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Meri Tibbs, Med. Room Coordinator and
Fernando Valadez, Covid-19 Reporting		TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection regarding Covid-19 reporting. LPA found the facility clean and at a comfortable temperature. LPA met with Meri Tibbs, Med. Room Coordinator and Fernando Valadez, who is the Infection Control Specialist, as well as the Dietary Supervisor.

LPA found that the facility is doing Response Testing and using the company Biocept for their PCR testing results, which is currently taking place weekly until two weeks of negative testing occurs. The last positive was reported on 6/9/22.

Positive results are reported to both CCL and Yolo County Department of Health. LPA requested that when positive cases are reported that the vaccination and testing dates are included. Biocept Lab is taking approximately 1 week for PCR testing results. Rapid response antigen tests are not used for the response testing, but the facility does have them available if needed. Negative test results are not required by CCL to be reported at this time.

There were no deficiencies or citations issued during this visit.

LPA reviewed the findings with Med. Room Coordinator, Meri Tibbs, whose signature accompanies report.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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