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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003494
Report Date: 02/28/2023
Date Signed: 02/28/2023 09:46:57 AM

Document Has Been Signed on 02/28/2023 09:46 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GREEN FIELD HAVENFACILITY NUMBER:
347003494
ADMINISTRATOR:KONONOV, LARISAFACILITY TYPE:
740
ADDRESS:3620 WINONA WAYTELEPHONE:
(916) 482-1314
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 6DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Larisa Kononov, AdministratorTIME COMPLETED:
10:00 AM
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On February 28, 2023, at 9am, (LPA) De Anna Williams-Lyons made an unannounced visit to conduct facilities required annual inspection. LPA met with Administrator Larisa Kononov and informed her the reason for the visit. The administrators certificate expires 7/25/2024.
LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked cabinet for medication storage. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. LPA observed the first aid kit to be complete. Fire extinguishers was fully charged.
Larisa and LPA completed the infectious control questionnaire with no issues.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.



The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than April 1, 2023.

An exit interview was conducted and a copy was given to Larisa.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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