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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585000879
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:54:25 AM

Document Has Been Signed on 09/20/2021 11:54 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WARNER'S FAMILY HOMEFACILITY NUMBER:
585000879
ADMINISTRATOR:WARNER, MICHAELFACILITY TYPE:
735
ADDRESS:4583 #C ARDMORE AVE.TELEPHONE:
(530) 743-2341
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 6CENSUS: 5DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Michael WarnerTIME COMPLETED:
01:45 PM
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9/20/2021 11:21 AM Licensing Program Analyst (LPA’s) Dawn Keane and Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA’s met with administrator (AD) Michael Warner and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. Additionally, LPA’s Keane and Valencia were screened by AD.

LPA’s Keane, Valencia and toured facility with AD to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, storage areas front yard and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA’s Keane, Valencia and the AD completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to AD.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Dawn Keane
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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