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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581372346
Report Date: 10/11/2023
Date Signed: 10/11/2023 10:42:05 AM

Document Has Been Signed on 10/11/2023 10:42 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 #4FACILITY NUMBER:
581372346
ADMINISTRATOR:MILLS, DOMINIQUEFACILITY TYPE:
775
ADDRESS:814 6TH STREETTELEPHONE:
(530) 742-7610
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 15CENSUS: 0DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dominique MillsTIME COMPLETED:
10:50 AM
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LPA Hiratsuka, conducted this unannounced annual visit.

This program is currently not in operation. LPA was able to contact the main office and Dominique Mills arrived to let LPA tour the inside. Since there are no clients attending, LPA advised Ms. Mills when the program starts again to notify when the program reopens.

A couple of topics were discussed.

No deficiencies cited during this visit.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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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