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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581370929
Report Date: 04/03/2024
Date Signed: 04/03/2024 01:07:16 PM

Document Has Been Signed on 04/03/2024 01:07 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 SERVICES #3FACILITY NUMBER:
581370929
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		MILLS, DOMINIQUEFACILITY TYPE:
775
ADDRESS:1020 F STREETTELEPHONE:
(530) 742-0420
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 26CENSUS: 21DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Cassendra SweetTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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LPA Hiratsuka, conducted this unannounced annual visit.

This facility has a fire clearance for all non-ambulatory clients. There are several common areas and an office. There are two bathrooms. The backyard has a locked shed. This program is starting to store their records electronically but is still available for review upon request.

Several staff and client files were reviewed.

Several topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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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