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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
581370663
Report Date:
12/14/2023
Date Signed:
12/14/2023 10:26:15 AM
Document Has Been Signed on
12/14/2023 10:26 AM
- 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 SERVICES #2
FACILITY NUMBER:
581370663
ADMINISTRATOR:
CATHY HULSEY
FACILITY TYPE:
775
ADDRESS:
730 I STREET
TELEPHONE:
(530) 742-1014
CITY:
MARYSVILLE
STATE:
CA
ZIP CODE:
95901
CAPACITY:
23
CENSUS:
13
DATE:
12/14/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:20 AM
MET WITH:
Cathy Hulsey
TIME COMPLETED:
10:30 AM
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LPA Hiratsuka conducted this unannounced annual visit.
This facility opens to the main common area. There is an office to the left of the main entrance. There are two client restrooms and one staff restroom. There is a separate building on the property that is not really used. This facility has a kitchen in the back.
Several topics were discussed.
No deficiencies cited
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/14/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/14/2023
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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