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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002951
Report Date: 10/03/2022
Date Signed: 10/03/2022 04:07:48 PM


Document Has Been Signed on 10/03/2022 04:07 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:LIVING WATER CARE HOME INC, THEFACILITY NUMBER:
345002951
ADMINISTRATOR:GUNAWAN, GRACEFACILITY TYPE:
740
ADDRESS:7800 CLAYPOOL WAYTELEPHONE:
(279) 529-2233
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 2DATE:
10/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Grace GunawanTIME COMPLETED:
04:30 PM
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On 10/3/2022 at 2:10 PM Licensing Program Analyst Parks arrived to conduct the prelicensing inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95.

LPA and Administrator completed the prelicensing inspection tool domain and the facility was found to be in substantial compliance. LPA and Administrator conducted a walk through of the facility and ensured all physical plant requirements.

Component III was conducted and completed with Administrator and employees Gabby and Herlina. LPA will notify CAB that the facility is ready for licensure.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
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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