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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001557
Report Date: 01/10/2024
Date Signed: 01/10/2024 04:00:43 PM

Document Has Been Signed on 01/10/2024 04:00 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:HARVEY CARE HOMEFACILITY NUMBER:
515001557
ADMINISTRATOR:HARVEY, JANAFACILITY TYPE:
735
ADDRESS:1144 JOSEPHTELEPHONE:
(530) 674-3526
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 6CENSUS: 6DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Theresa ManalangTIME COMPLETED:
04:10 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Caregiver Theresa Manalang.

The main entrance opens to the main common area that includes sitting, dining, and kitchen. To the left of the main common area is a hallway leading to the three shared resident rooms and one full common bathroom and the largest room has a full bathroom. To the right of the main entrance is a sitting area. Next to the dining room is the laundry room that leads to a staff area that has two staff rooms and a staff bathroom from the staff area. There is a door leading to the backyard from the dining room. There is a detached garage.

Three resident files were reviewed.
Staff files were reviewed.

The following shall be updated and submitted to Community Care Licensing Division by 01/30/2024:
-LIC 500 Facility personnel 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: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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