<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 517003360
Report Date: 01/08/2025
Date Signed: 01/08/2025 02:06:10 PM

Document Has Been Signed on 01/08/2025 02:06 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:WILFREDO A. CHICO'S HOMEFACILITY NUMBER:
517003360
ADMINISTRATOR/
DIRECTOR:
CHICO, WILFREDO A.FACILITY TYPE:
735
ADDRESS:1583 COUNTRYSIDE DRIVETELEPHONE:
(530) 755-1579
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 6CENSUS: 6DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Joanna MelendresTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Hiratsuka and Yang, conducted this unannounced annual visit.

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.

Today, LPAs observed a room in the garage. LPAs asked when the room was constructed and LPAs were informed it was sometime in 2020, to be used as an isolation room for during the covid pandemic. Because LPA Hiratsuka didn't notice the room in the garage during previous annual inspections, a citation is not going to be issued. However, Licensee is to submit a copy of finalized permits from the planning department that allows the room to be used a room that may be lived in if the Licensee wishes to keep the room as a staff room. LPA shall order an updated fire clearance for the facility. If the licensee does not want to use the room to be used as a staff room the room shall be torn down or Licensee may submit a finalized copy of the permits to use it as storage.

Medications reviewed. Six resident records were reviewed. Three staff files were reviewed.

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)
Page: 1 of 1