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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002783
Report Date: 01/11/2023
Date Signed: 01/11/2023 10:40:38 AM

Document Has Been Signed on 01/11/2023 10:40 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:NICOLET HOME INCFACILITY NUMBER:
455002783
ADMINISTRATOR:OSTERMAN, RUSSELLFACILITY TYPE:
735
ADDRESS:2958 NICOLET LANETELEPHONE:
(530) 262-5002
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 6CENSUS: 4DATE:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Angel Doss TIME COMPLETED:
10:50 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing masks. LPA was screened at the door by the caregiver.

The main entrance opens to a small foyer. There is a resident room the left of the main entrance. There is a hallway to the left of the main entrance past the first resident room that leads to one bedroom that has a full private bathroom and a sliding door to the backyard, and a laundry room. The laundry room also has a door leading to the garage. To the right of the main entrance is a hallway that leads to two resident rooms and one full private bathroom. The kitchen, dining, and main sitting area are in the back of the facility.

A couple of topics were discussed.

***Due to resident safety, LPA Hiratsuka has suggested that all postings that are supposed to be hung on the wall be put into binders, marked appropriately, and available for review upon request..***


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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