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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
515000960
Report Date:
09/28/2023
Date Signed:
09/28/2023 10:40:59 AM
Document Has Been Signed on
09/28/2023 10:40 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
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
COMMUNITY RESOURCE SERVICES #5
FACILITY NUMBER:
515000960
ADMINISTRATOR:
TERESA VILLA
FACILITY TYPE:
775
ADDRESS:
732 PLUMAS STREET
TELEPHONE:
(530) 751-2026
CITY:
YUBA CITY
STATE:
CA
ZIP CODE:
95991
CAPACITY:
49
CENSUS:
43
DATE:
09/28/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Teresa Villa
TIME COMPLETED:
10:50 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Program Coordinator Teresa Villa arrived during visit.
This program is in a building that has an entrance on the side that leads to a parking lot and has a ramp on the inside. The front entrance opens into an area that sells the art the clients make. There is a partition that separates the store from the work space for the clients. There is a snack area towards the back just before the doorway in the back on the right. In the back there are a couple of storage areas and a restroom for the clients and staff of the program only. There is a kitchen area on the second floor in the back.
Several topics were discussed
The following shall be updated and submitted to Community Care Licensing by 10/15/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/28/2023
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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