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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 517003688
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:02:42 PM

Document Has Been Signed on 07/18/2024 12:02 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COMMUNITY RESOURCE SERVICESFACILITY NUMBER:
517003688
ADMINISTRATOR/
DIRECTOR:
DOMINIQUE MILLSFACILITY TYPE:
775
ADDRESS:903 CHESTNUT STTELEPHONE:
(530) 751-0317
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 20CENSUS: 19DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Assistant Program Manager Donna Mallett and Dominque MillsTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Assistant Program Manager Donna Mallett. Administrator Dominique Mills showed showed up during visit.

This building has two large main common areas, and one office. Last year after LPA conducted the annual this building underwent minor remodeling. The wall between the quiet room and one of the large common rooms was knocked down to make one large room. The second large common area is now used as the quiet room for clients and there is a door that can be closed to ensure the client gets privacy. No new fire clearance is required because it did not affect the capacity nor did it add any rooms. 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.

Multiple topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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