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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001644
Report Date: 07/22/2024
Date Signed: 07/23/2024 09:17:23 AM

Document Has Been Signed on 07/23/2024 09:17 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:MARCELLA GREEN FAMILY HOMEFACILITY NUMBER:
317001644
ADMINISTRATOR/
DIRECTOR:		GREEN, LINFACILITY TYPE:
735
ADDRESS:11742 JONES STREETTELEPHONE:
(530) 863-8866
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 3DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Marcella GreenTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 7/22/2024 LPA Tryon visited the facility to do an annual visit. LPA met with licensee Marcella Green.
LPA toured the house including common areas, kitchen, bedrooms, bathrooms, storage, yard.
The house appears to be in general compliance overall. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Medications, cleaners, knives, etc. are secured. LPA reviewed client files and staff files, Emergency/Disaster plan, etc. Smoke detectors installed, fire extinguisher present and fully charged. No hazards or obstructions noted.

LPA reviewed the CARES Tool with licensee.
LPA reviewed 3 resident files, and one staff files. Files include required information.

Licensee appears to be in general compliance. LPA found no deficiencies at this visit.



Exit interview conducted, Appeal Rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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