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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000625
Report Date: 05/02/2024
Date Signed: 05/02/2024 12:44:30 PM

Document Has Been Signed on 05/02/2024 12:44 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ACE-IT IIIFACILITY NUMBER:
515000625
ADMINISTRATOR/
DIRECTOR:		AMY FULKFACILITY TYPE:
775
ADDRESS:1670 SIERRA AVE, SUITE 601TELEPHONE:
(530) 673-4585
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 60CENSUS: 50DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Amy FulkTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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LPA Hiratsuka conducted this unannounced annual visit.

This facility has a fire clearance for thirty ambulatory and thirty non-ambulatory clients for a total of sixty clients. There are multiple rooms for classrooms, storage, changing areas, and offices. There are a couple of large common areas. There are two kitchen areas and one is larger than the other. There are several half-bathrooms throughout the facility. There were many different activities occurring during visit.

Multiple topics discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 20, 2024:
-LIC 308 designation of administrative responsibility
-LIC 500 facility personnel or staff schedule



no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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