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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
581374809
Report Date:
04/03/2024
Date Signed:
04/03/2024 11:18:13 AM
Document Has Been Signed on
04/03/2024 11:18 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 #6
FACILITY NUMBER:
581374809
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:
MILAM, BEVERLEE
FACILITY TYPE:
775
ADDRESS:
915 H STREET
TELEPHONE:
(530) 742-0952
CITY:
MARYSVILLE
STATE:
CA
ZIP CODE:
95901
CAPACITY:
20
CENSUS:
DATE:
04/03/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:
Beverlee Milan
TIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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LPA Hiratsuka conducted this unannounced annual visit.
This facility has a fire clearance for seventeen non-ambulatory and three ambulatory clients. This building has several common areas and an office area. There is a quiet room. There are ramps. The facility is transitioning to having their records stored electronically and they are available for review upon request.
Multiple topics were discussed.
Several staff files and several client files were reviewed.
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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