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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 471304415
Report Date: 11/16/2022
Date Signed: 11/16/2022 09:52:01 AM


Document Has Been Signed on 11/16/2022 09:52 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:YREKA GUEST HOMEFACILITY NUMBER:
471304415
ADMINISTRATOR:CRANE, SANDEE JOYFACILITY TYPE:
740
ADDRESS:520 N. MAINTELEPHONE:
(530) 842-4235
CITY:YREKASTATE: CAZIP CODE:
96097
CAPACITY:12CENSUS: 8DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Sandee CraneTIME COMPLETED:
10:00 AM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask during the visit.

This facility has a fire clearance for four non-ambulatory and eight ambulatory residents. This facility has three levels: main level, second story, and basement. There are also two separate living quarters: one houses staff and one is cleared to house two residents. The main house main level has two shared resident rooms and one full common bathroom, kitchen, dining, main sitting area, and a laundry room. The second floor has five resident rooms with one being a shared and one full common bathroom. There is a basement that is used for storage.

Two resident records and one staff record were reviewed.

Several topics were discussed

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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