<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297000914
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:11:48 PM

Document Has Been Signed on 10/07/2024 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:HOUSTON AND NOBLES ADULT RESIDENTIAL CAREFACILITY NUMBER:
297000914
ADMINISTRATOR/
DIRECTOR:
MARK & BARBARA HOUSTONFACILITY TYPE:
735
ADDRESS:21706 JOHN BORN ROADTELEPHONE:
(530) 432-3399
CITY:PENN VALLEYSTATE: CAZIP CODE:
95946
CAPACITY: 6CENSUS: 5DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Josh Houston, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Tryon visited the facility unannounced to do an annual visit. LPA met with Administrator Josh Houston. LPA toured the house including common areas, bedrooms, bathrooms, kitchen, food storage, hallways, outside, etc.

The home is well-furnished. Food supplies are plentiful and varied. Medications are centrally stored and locked. Guns and ammunition are locked separately.

LPA reviewed 2 staff files and 2 resident files. Files contain required information.

LPA completed the CARE Tool with Administrator.

LPA interviewed one staff and one resident who was available.

Smoke and carbon monoxide detectors are installed, fire extinguisher present and recently charged.

At this time the facility appears to be in substantial compliance with the regulations. No deficiencies were noted at this visit.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1