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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297000914
Report Date: 11/08/2023
Date Signed: 11/09/2023 12:18:15 PM

Document Has Been Signed on 11/09/2023 12:18 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:HOUSTON AND NOBLES ADULT RESIDENTIAL CAREFACILITY NUMBER:
297000914
ADMINISTRATOR:MARK & BARBARA HOUSTONFACILITY TYPE:
735
ADDRESS:21706 JOHN BORN ROADTELEPHONE:
(530) 432-3399
CITY:PENN VALLEYSTATE: CAZIP CODE:
95946
CAPACITY: 6CENSUS: 6DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mark Houston and Josh Houston, AdministratorTIME COMPLETED:
04:30 PM
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On 11/8/2023 LPA visited the facility to conduct an annual visit. LPA met with Mark Houston and Administrator Josh Houston.
LPA toured the facility including common areas, kitchen, food storage areas, bedrooms, hallways, bathrooms, outside areas.
The house is appropriately furnished, bedrooms have appropriate furniture and personal belongings. Medications are centrally stored and locked in a cabinet, logs are maintained. The home has smoke detectors and carbon monoxide detectors, fire extinguishers.
The facility has appropriate supplies of bedding, towels, etc.
Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable goods.
No hazards noted.
LPA reviewed the CARE Tool with staff, reviewed staff files, etc.
The home has an emergency/disaster plan, infection control plan, etc.
Temperature in the home was comfortable.

LPA interviewed staff and resident,

At this time, the facility appears to be in substantial compliance with regulations.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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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