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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002987
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:27:49 PM

Document Has Been Signed on 01/25/2023 12:27 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:MID VALLEY PROVIDERS #5FACILITY NUMBER:
455002987
ADMINISTRATOR:DORE, SHANNONFACILITY TYPE:
735
ADDRESS:3638 CHERRYWOOD DRIVETELEPHONE:
(530) 605-1977
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 0DATE:
01/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Debbie LamourTIME COMPLETED:
12:35 PM
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LPA Hiratsuka conducted this announced prelicensing visit. LPA wore a surgical mask and observed Co-Licensee Debbie Lamour wearing mask. Co-Licensee Patti Moore arrived for part of the visit. This is a change-of-location visit.

This facility has a fire clearance one non-ambulatory and three ambulatory residents. The main entrance opens to a small foyer. Across is a common area. To the left is a hallway leading to four private resident rooms and one full common bathroom. One resident room has an exit to the outside and a full private bathroom. To the right is the kitchen, dining, laundry room, and a door leading to the garage from the kitchen. The laundry room has a common half-bathroom. The backyard has three locked sheds. There is a gate on the same side as the garage.

Several topics discussed.

This facility meets regulations. LPA is going to submit this report to the application specialist.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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