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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001644
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:08:02 PM

Document Has Been Signed on 08/29/2022 03:08 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MARCELLA GREEN FAMILY HOMEFACILITY NUMBER:
317001644
ADMINISTRATOR:GREEN, MARCELLAFACILITY TYPE:
735
ADDRESS:11742 JONES STREETTELEPHONE:
(530) 863-8866
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 3DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marcella GreenTIME COMPLETED:
04:00 PM
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On 8/29/2022 LPA Tryon visited the facility unannounced to do an annual visit. The visit was conducted using the Infection Control Domain of the CARES Tool
LPA toured the facility including kitchen, living room, bedrooms, bathroom, laundry, food storage The faciity is currently undergoing some house renovations
The home has adequate supplies of food including fresh and dry goods, PPE, cleaners, etc.
We discussed the required Infection Control Plan that is now due.

At this time, no deficiencies were cited.

Exit interview conducted.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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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