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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 517003688
Report Date: 08/17/2023
Date Signed: 08/17/2023 01:28:25 PM

Document Has Been Signed on 08/17/2023 01:28 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: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: DATE:
08/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Donna MallettTIME COMPLETED:
01:35 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Assistant Program Manager Donna Mallett.

This building has two large main common areas, one office, and one quiet room. There is a kitchen. There are two common bathrooms. There is an ample supply of cleaning products that are locked up when not in use. No health and safety issues were observed during this visit.

Several staff and client records were reviewed.

Several topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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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