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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 517003688
Report Date: 06/28/2022
Date Signed: 06/28/2022 02:05:47 PM

Document Has Been Signed on 06/28/2022 02:05 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:COMMUNITY RESOURCE SERVICESFACILITY NUMBER:
517003688
ADMINISTRATOR:COURTNEY, JESSICAFACILITY TYPE:
775
ADDRESS:903 CHESTNUT STTELEPHONE:
(530) 751-0317
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 20CENSUS: 0DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jessica CourtneyTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 06/28/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Program Administrator Jessica Courtney and explained the purpose of the visit. Prior to initiating the annual inspection visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Jessica Courtney.

LPA and facility staff toured facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, common bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time. LPA arrived at this day program after the clients went home for the day.

Facility is to update the following by July 15, 2022:
-LIC 500 facility personnel or a staff schedule
-LIC 308 Designation of Administrative Responsibility

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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