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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585000879
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:22:10 PM

Document Has Been Signed on 08/31/2023 03:22 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: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: 4DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michael Warner and Kathleen Warner TIME COMPLETED:
03:30 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Michael Warner.

This facility has two floors. The second floor is the licensee's living quarters. There are three shared resident rooms and one staff room on the first floor. The first floor is the main area for the residents. There is a pool that is surrounded by a locked fence. There is an ample supply of perishable and non-perishable.

Two staff and two resident records were reviewed.

A couple of topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by September 15, 2023:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-LIC 610 emergency disaster plan.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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