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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 517003360
Report Date: 12/29/2022
Date Signed: 12/29/2022 03:02:12 PM

Document Has Been Signed on 12/29/2022 03:02 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WILFREDO A. CHICO'S HOMEFACILITY NUMBER:
517003360
ADMINISTRATOR:CHICO, WILFREDO A.FACILITY TYPE:
735
ADDRESS:1583 COUNTRYSIDE DRIVETELEPHONE:
(530) 755-1579
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 6CENSUS: 6DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Joanna MelendresTIME COMPLETED:
03:10 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing masks.

The main entrance opens into a sitting area on the right. Past the sitting area in the back is the main common, dining, and kitchen area. To the left of the main entrance is a hallway that leads to three shared resident rooms, the laundry room, a full common bathroom, and staff room. The largest resident room has a full private bathroom. The backyard has a locked storage shed in it. The gate is on the same side as the garage.

Two of six resident records were reviewed
Two staff files were reviewed.

Several topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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