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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581370663
Report Date: 01/08/2025
Date Signed: 01/08/2025 10:32:55 AM

Document Has Been Signed on 01/08/2025 10:32 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 #2FACILITY NUMBER:
581370663
ADMINISTRATOR/
DIRECTOR:		CATHY HULSEYFACILITY TYPE:
775
ADDRESS:730 I STREETTELEPHONE:
(530) 742-1014
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 23CENSUS: 11DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Cathy HulseyTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Licensing Program Analysts (LPAs) Yang and Hiratsuka arrived to conduct an unannounced annual visit.

During today's inspection, LPAs observed clients participating in activities in the common area. 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 used for meal prep. This facility has a kitchen in the back.

LPAs conducted file review and observed the required documents present.

The following shall be updated and submitted to Community Care Licensing Division by the end of the month
-LIC 308 designation of administrative responsibility
-LIC 500 facility personnel or staff schedule


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)
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