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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701032
Report Date: 12/16/2022
Date Signed: 12/20/2022 01:43:46 PM

Document Has Been Signed on 12/20/2022 01:43 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 0DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shane LibbyTIME COMPLETED:
03:30 PM
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LPA met with Shane Libby to do a quick annual visit, using the Infection Control Domain of the CARES Tool.

LPA toured the facility including all areas. At this time, the home does not have residents or staff; the license is still valid, and the agency still plans to open the house soon, hopefully within a few months.

The house appears to be ready for occupancy. There are no violations or hazardous conditions noted in the house.

No deficiencies cited. Exit interview conducted.


SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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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