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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002569
Report Date: 08/18/2022
Date Signed: 08/18/2022 03:15:39 PM

Document Has Been Signed on 08/18/2022 03:15 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GUANZON'S RESIDENTIAL CARE #3FACILITY NUMBER:
585002569
ADMINISTRATOR:GUANZON, LORENAFACILITY TYPE:
735
ADDRESS:5932 VINE COURTTELEPHONE:
(530) 741-0891
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 3DATE:
08/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Lorena GuanzonTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Case Management Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Caregiver.

LPA conducted this visit in response to an incident reported a resident passed away. LPA obtained some paperwork from the resident's file and requested a copy of other things. Further inquire is required.

Several other topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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