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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002631
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:24:58 PM

Document Has Been Signed on 12/01/2022 03:24 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:AAVON CARE HOME #1FACILITY NUMBER:
585002631
ADMINISTRATOR:BAL, JAGDEEPFACILITY TYPE:
735
ADDRESS:2058 MOSS GLEN LOOPTELEPHONE:
(530) 701-4037
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Benita Velenzuela LopezTIME COMPLETED:
03:30 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask during visit and observed staff wearing masks.

The main entrance opens into a small common area. There is an office area to the right of the main entrance. There is a private room to the right of the main entrance. To the left of the main entrance has a hallway leading to to three private bedrooms, laundry room, one full common bathroom, the largest of the three bedrooms has a full private bathroom and an exit to the outside, and a door leading to the garage. The back of the facility has the main common, dining, and kitchen area. There are locked cabinets for confidential information and medications.

The following shall be updated and submitted to licensing within 30 days;
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: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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