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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581302894
Report Date: 01/26/2022
Date Signed: 01/27/2022 02:59:30 PM

Document Has Been Signed on 01/27/2022 02:59 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:FEATHER RIVER MANORFACILITY NUMBER:
581302894
ADMINISTRATOR:TERRY, NORAFACILITY TYPE:
740
ADDRESS:3962 WEST ELLA AVE.TELEPHONE:
(530) 743-5022
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 32CENSUS: 30DATE:
01/26/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Scott Terry, LicenseeTIME COMPLETED:
03:00 PM
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On 1/26/22 around 1:00 pm Licensing Program Analyst (LPA) Mai Thao conducted a case management visit with Licensee, Scott Terry, to provide additional infection control guidance to help control the spread COVID. Also joining the visit was Shantala Ahanya, Healthcare-Associated Infections (HAI) Program Center for Health Care Quality California Department of Public Health (CDPH).

Prior to visit, 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, Face Shield, Gloves, and Gown.

The purpose of the visit is to evaluate the facility to ensure infection control measures are followed. During the inspection screening process for staff and visitors was observed and PPE was evaluated. Licensee also toured the front entrance bathroom to ensure hand washing is available.

During this inspection the Department and facility representatives discussed the cohorting of staff and positive residents, positive residents continuing to isolate with non-positive residents, face shield/eye protection for staff, hand hygiene for residents before and after smoking and eating. LPA, Shantala Ahanya, and Licensee toured the facility, but not limited to, Entrance, Entrance Area, Bathroom, Resident Bedroom, and Common Area.

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SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: FEATHER RIVER MANOR
FACILITY NUMBER: 581302894
VISIT DATE: 01/26/2022
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Recommendations discussed:
· Screening of residents with COVID and under observation
· Training of staff, donning and doffing
· cohorting COVID and Non-COVID residents
· increased air circulation inside the facility
· encouraged mask wearing for residents
· encouraging staff/Residents to wear N95/KN95
· plan on mitigating residents who goes out of the facility

The Licensee agreed to do the following:
· have screening protocol in place
· have the proper PPE available for staff
· have an isolation room and bathroom available for cohorting COVID positive residents
· open windows for air circulation and purchase portable air purifier (HEFA Filtered)
· encourage residents to wear mask indoor, as tolerable
· encourage staff to wear N95 mask/KN95
· encourage positive resident to wear N95 mask when out of their room (KN95 is okay)

Licensee agreed to implement these mitigation practices at the facility.

The Department will continue to provide assistance with daily calls with the facility until it has been cleared by local public health. Facility will continue to provide the department daily line list until cleared by the public health.

LPA advised Licensee to screen ALL visitors and staff prior to entry to the facility. LPA also advised Licensee to report all positive COVID-19 cases to Licensing, Public Health, and other reporting parties as soon as facility find out.

Exit Interview Conducted and a copy of this report was left with Licensee, Scott Terry, at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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