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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002905
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:27:34 AM


Document Has Been Signed on 05/20/2022 11:27 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ROBBINS HOME LLCFACILITY NUMBER:
095002905
ADMINISTRATOR:ROBBINS, HILARYFACILITY TYPE:
735
ADDRESS:2532 EAGLE LANETELEPHONE:
(530) 363-0715
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:4CENSUS: 3DATE:
05/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Cheyanne FincherTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Prelicensing visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Caregiver. LPA toured the facility with Caregiver Cheyanne Fincher. Applicant Hilary Robbins arrived during LPA's visit and completed visit with LPA.

This facility is undergoing a change of ownership. This facility has a fire clearance for four ambulatory residents only. This facility is split level. The main entrance opens to a sitting and office area. Directly to the left is the staircase that leads to three resident rooms, one common bathroom, and one staff room. The largest resident room has a full private bathroom. To the left of the main entrance past the staircase leading upstairs is a short staircase going down leading to an activity area, common half bathroom, laundry closet, door leading to the backyard, and door leading to the garage. To the right of the main entrance is a sitting area, office area, dining area, and kitchen. Facility has ample food supply. There is a locked cabinet for medication in the dining area. The backyard has a locked shed in it.

Component three orientation waived by LPA because the applicant already owns and operates another facility.

Multiple topics were discussed

This facility meets regulations. LPA is going to submit this to the application specialist.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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