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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 471372608
Report Date: 11/17/2022
Date Signed: 11/17/2022 10:47:17 AM

Document Has Been Signed on 11/17/2022 10:47 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:BARKERS RESIDENTIAL CAREFACILITY NUMBER:
471372608
ADMINISTRATOR:DAUSEL, CYNDIFACILITY TYPE:
735
ADDRESS:200 4TH STREETTELEPHONE:
(530) 905-1409
CITY:MONTAGUESTATE: CAZIP CODE:
96064
CAPACITY: 15CENSUS: 12DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:House Manager David Small and Administrator Erica Timberlake TIME COMPLETED:
10:55 AM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore surgical mask and observed all staff wearing surgical masks.

This facility has a fire clearance for 15 ambulatory only residents. The main entrance opens to the main sitting area. There are two full common bathrooms in the middle of the facility and the bedrooms are across from them on both sides. The hallways lead to the back where there are two short hallways on both sides that have exits to the outside. One resident room has a full private bathroom. The kitchen is in the very back and also has food storage and medication storage. There is another building on the left of the facility that has one resident room and the laundry room. The laundry room currently doesn't work; however, the laundry is getting done by the administrator and house manager.

Today, the following was discussed:
-staff training logs
-current administrator
-annual fees- this facility currently owes $2722.50. House Manager acknowledged the fees are overdue and requested to do a payment plan. LPA gave instructions on how to apply for a payment plan.
-resident files
-staff files
-updating program design for this facility.



SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BARKERS RESIDENTIAL CARE
FACILITY NUMBER: 471372608
VISIT DATE: 11/17/2022
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The following shall be submitted to Community Care Licensing Division by 11/23/2022:
-request for payment plan for annual fee
-updated facility sketch

The following shall be updated and submitted to Community Care Licensing Division by December 17, 2022:
-LIC 500 or staff schedule
-LIC 308- designation of administrative responsibility

Multiple topics were discussed.


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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