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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001557
Report Date: 01/08/2025
Date Signed: 01/08/2025 02:59:44 PM

Document Has Been Signed on 01/08/2025 02:59 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/
DIRECTOR:		HARVEY, JANAFACILITY TYPE:
735
ADDRESS:1144 JOSEPHTELEPHONE:
(530) 674-3526
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 6CENSUS: 6DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Kiera DavisTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Yang and Hiratsuka conducted this unannounced annual visit. LPAs conducted a tour with Caregiver.

Tour of the facility, 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.

Adequate food supplies were observed.

Staff and resident files were reviewed.

The following shall be updated and submitted to Community Care Licensing Division by 01/31/2025:
-LIC 500 Facility personnel or staff schedule
-LIC 308 Designation of Administrative Responsibility


Inspection tool completed and no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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