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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002974
Report Date: 01/10/2023
Date Signed: 01/10/2023 02:25:22 PM


Document Has Been Signed on 01/10/2023 02:25 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:COUNTRY OAKS SENIOR LIVINGFACILITY NUMBER:
455002974
ADMINISTRATOR:JOHNSON, MELISSAFACILITY TYPE:
740
ADDRESS:847 COUNTRY OAK DRTELEPHONE:
(530) 605-4437
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 0DATE:
01/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Melissa Johnson and Evelyn Lander-WilliamsTIME COMPLETED:
02:35 PM
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LPA Hiratsuka conducted this announced pre-licensing visit. LPA wore a surgical mask and observed the applicants wearing the surgical masks.

The main entrance opens to a sitting area on left. To the right on of the main entrance there is a hallway leading to the four private resident rooms, a full common bathroom, storage, and a door leading to the garage. The largest of the resident rooms has a full private bathroom. The main sitting, dining, and kitchen area is in the back of the facility. There is a small shed in the back that can be used for activities or storage, but no one may live in there.

Component III has been waived due to Applicant owning multiple facilities.

Several topics were discussed.

This facility meets regulations. LPA is going to submit this report to the application specialist.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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