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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701032
Report Date: 08/09/2023
Date Signed: 08/14/2023 08:58:30 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/14/2023 08:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:AMI HOUSING, INC.FACILITY NUMBER:
312701032
ADMINISTRATOR:LIBBY, SHANEFACILITY TYPE:
735
ADDRESS:1720 LILAC LANETELEPHONE:
(530) 878-5088
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:15CENSUS: 3DATE:
08/09/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Shane Libby, AdministratorTIME COMPLETED:
04:30 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
8-9-2023 LPA Tryon visited the facility to complete the annual. LPA met with Administrator Libby Shane, Jesse Williams, Director of Housing Services and Leigh Albright, Program Supervisor. We reviewed the CARE Tool. The facility is in substantial compliance with the regulations.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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