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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002734
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:36:19 AM

Document Has Been Signed on 11/30/2023 10:36 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:INNOVATIONSFACILITY NUMBER:
045002734
ADMINISTRATOR:GREEN, SEANFACILITY TYPE:
775
ADDRESS:1015 MANGROVE AVETELEPHONE:
(530) 899-1907
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY: 35CENSUS: 21DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator- Sean Green TIME COMPLETED:
10:45 AM
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On 11/30/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Sean Green and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of participants in the program.

Areas toured include but are not limited to: common areas, classrooms and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary paper towels and trash can with lids. The program had ample amount of supplies for activities with a full schedule of a variety of activities for participants.

LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and four (4) staff files which contained all the required documentation.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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