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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000683
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:15:13 AM


Document Has Been Signed on 07/13/2022 11:15 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:COURTYARD, THEFACILITY NUMBER:
515000683
ADMINISTRATOR:PICKARD, CAROLFACILITY TYPE:
740
ADDRESS:1240 WILLIAMS WAYTELEPHONE:
(530) 790-3050
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:80CENSUS: 51DATE:
07/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Carol PickyardTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Case Management Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk.

LPA conducted this visit in response to an incident reported last week by Director of Assisted Living Services Carol Pickard. A resident died unexpectedly on 07/06/2022. LPA discussed the incident and at this time no extra documentation is required. Further investigation is required.

Several other 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: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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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