<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002813
Report Date: 10/07/2021
Date Signed: 10/07/2021 11:00:55 AM

Document Has Been Signed on 10/07/2021 11:00 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 FAMILY COTTAGEFACILITY NUMBER:
585002813
ADMINISTRATOR:WARNER, KARENFACILITY TYPE:
735
ADDRESS:1122 H ST.TELEPHONE:
(530) 870-8504
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 0DATE:
10/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karen Warner & Michael Warner; LicenseeTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/7/21 at 9 AM, Licensing Program Analyst (LPA) Cheng conducted an announced required prelicensing and met with Licensees Karen & Michael Warner. Prior to initiating the visit, 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; 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: surgical mask. Additionally, LPA was screened by Licensee Karen Warner.

On 10/7/21 at 9AM, LPA Cheng toured the facility inside and out including but not limited to facility kitchen, dining room, both facility bathrooms, hallways, outside area, living room, office/staff room, and resident rooms. All passage ways were free of obstruction and body of waters. All bathrooms are equipped with paper towels on a rack holder, hand soaps, and step-pedal trash bins. All medications are centrally stored in a locked cabinet in the kitchen area. Facility has a 2-day perishable and 7-day non-perishable supply of food. Outside area has a designated seating area with a covering. Fire extinguishers were observed to be full and operational. Facility's smoke and carbon monoxide detectors were observed to be operational. Facility has two first aid kits located at each end of the building.

LPA Cheng completed infection control domain and observed no issues or concerns. LPA will e-mail additional infection control posters to add to existing ones in the facility.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAB. Additional requirements may still be required. COMP III waived.

Exit interview conducted and a copy of report was given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1