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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
515000960
Report Date:
10/10/2024
Date Signed:
10/10/2024 10:05:47 AM
Document Has Been Signed on
10/10/2024 10:05 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/
DIRECTOR:
TERESA VILLA
FACILITY TYPE:
775
ADDRESS:
732 PLUMAS STREET
TELEPHONE:
(530) 751-2026
CITY:
YUBA CITY
STATE:
CA
ZIP CODE:
95991
CAPACITY:
49
CENSUS:
48
DATE:
10/10/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
Krystal Robertson
TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Program Coordinator Assistant Krystal Robertson. LPA observed all the clients doing various activities in the work space.
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.
The following shall be updated and submitted to Community Care Licensing by 10/30/2024:
-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:
10/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/10/2024
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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