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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001368
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:45:09 PM

Document Has Been Signed on 09/14/2022 02:45 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:THREE PINES ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
317001368
ADMINISTRATOR:SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:1450 OAK RIDGE WAYTELEPHONE:
(530) 885-5181
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 6DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Chris ChuTIME COMPLETED:
03:30 PM
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On 9/14/2022 LPA visited the facility to do an annual visit using the Infection Control Domain of the CARES Inspection tool. LPA was greeted by Administrator Chris Chu.

LPA reviewed the Infection Control Domain.

LPA toured the house including common areas, kitchen, food supplies, bedrooms, bathrooms, storage, yard, etc.

The home appears to have adequate supplies of food both perishable and non-perishable, good supplies of cleaners, PPE, etc.

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

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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