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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920015
Report Date: 06/07/2023
Date Signed: 06/07/2023 02:54:22 PM

Document Has Been Signed on 06/07/2023 02:54 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:TEHAMA MANORFACILITY NUMBER:
045920015
ADMINISTRATOR:BRAY, DAWNFACILITY TYPE:
735
ADDRESS:65 BRENDA DRIVETELEPHONE:
(530) 838-3898
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 3CENSUS: 0DATE:
06/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Renee RhodesTIME COMPLETED:
03:14 PM
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Licensing Program Analysts Kerry Hiratsuka and Jaynae Boyles, conducted this announced prelicensing visit.

This facility has a fire clearance for three ambulatory only residents. This facility has three private resident rooms and one office. The office and hallway to the resident rooms, and one full common bathroom are to the right of the main entrance. The largest of the resident rooms has a full private bathroom and an exit to the outside. The common areas, door leading to the garage, and kitchen are to the left of the main entrance. The garage has the clothes washer and dryer. The backyard is split into two areas: one that is going to be a garden that has a locked shed and the area is locked and does not have a gate that leads to the front yard. The other part of the backyard has a gate leading to the front yard.

Several topics were discussed.

Component III orientation was waived due to this being a change of location.


This facility meets regulations. LPA is going to submit this report to the application specialist.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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