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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002656
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:53:13 AM

Document Has Been Signed on 01/18/2024 10:53 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:CLAUDIA S. COOK HOME #2FACILITY NUMBER:
585002656
ADMINISTRATOR:COOK, JEAN-CLAUDEFACILITY TYPE:
735
ADDRESS:11536 JUDY STTELEPHONE:
(530) 763-1703
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Jean-Claude and Deshawn CookTIME COMPLETED:
11:00 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA met with Administrator Jean-Claude Cook and House Manager Deshawn Cook.

This facility is connected to the living quarters of the caregiver by a door inside. The living quarters of the caregivers has an entrance and the facility portion has its own entrance. The entrance to the facility is on the left of the building. The main entrance to the facility opens to the main common area. To the right of the main entrance are two private resident rooms, a small sitting room that has a door connecting to the caregiver's side, and the full common bathroom. To the left of the main entrance is a doorway that leads to a small common room that connects to two private resident rooms and a staircase leading to a room with a full bathroom. The staircase and the area it leads to is off-limits to the residents. The main common area has a dining area and kitchen.

Staff and resident records were reviewed.


Multiple topics were discussed during this visit.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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