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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
065001970
Report Date:
04/03/2024
Date Signed:
04/03/2024 04:11:53 PM
Document Has Been Signed on
04/03/2024 04:11 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
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
COLUSA SUPPORT SERVICES-FIFTH STREET RESIDENCE
FACILITY NUMBER:
065001970
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:
NATALIE AYALA
FACILITY TYPE:
735
ADDRESS:
645 FIFTH STREET
TELEPHONE:
(530) 458-2774
CITY:
COLUSA
STATE:
CA
ZIP CODE:
95932
CAPACITY:
4
CENSUS:
4
DATE:
04/03/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:
Anita Stuck
TIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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LPA Hiratsuka conducted this unannounced annual visit.
This facility has four private resident rooms and one staff room. There is one room that has a full private bathroom and there is one full common bathroom. The backyard has a greenhouse.
Several topics were discussed.
The following shall be updated and submitted to Community Care Licensing Division by 04/20/2024:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/03/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/03/2024
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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