<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 471372608
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:49:47 AM

Document Has Been Signed on 05/16/2023 11:49 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:BARKERS RESIDENTIAL CAREFACILITY NUMBER:
471372608
ADMINISTRATOR:DAUSEL, CYNDIFACILITY TYPE:
735
ADDRESS:200 4TH STREETTELEPHONE:
(530) 905-1409
CITY:MONTAGUESTATE: CAZIP CODE:
96064
CAPACITY: 15CENSUS: 13DATE:
05/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Erica Timberlake TIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka, conducted this unannounced case management visit. This is in response to the licensee not contacting Community Care Licensing Division to pay their annual fees.

On 11/17/2022, LPA was informed House Manager David Small and Administrator Erica Timberlake, they knew the annual fees were late and Mr. Small stated he wanted to set up a payment plan. LPA Hiratsuka agreed and waited for a call from Mr. Small. As of today LPA did not receive the phone call.

Licensee owes as of 05/12/2023, $3,062.50. LPA is issuing a citation regarding the nonpayment of annual fees.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit Interview conducted and appeal rights provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/16/2023 11:49 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 05/16/2023 at 11:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BARKERS RESIDENTIAL CARE
FACILITY NUMBER: 471372608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
HSC
1523.1(a)(1)

1
2
3
4
5
6
7
An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license.
1
2
3
4
5
6
7
By May 31, 2023, the licensee shall at minimum contact Community Care Licensing to discuss payment of the annual fees or pay the entire fee due. Failure to correct shall result in civil penalites.
8
9
10
11
12
13
14
This requirement has not been met as evidenced by:
Based on LPA's review of annual fees not being paid. This does not pose an immediate risk to residents.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2