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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002813
Report Date: 10/07/2021
Date Signed: 10/07/2021 11:01:35 AM

Document Has Been Signed on 10/07/2021 11:01 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karen Warner & Michael Warner; LicenseeTIME COMPLETED:
11:00 AM
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On 10/7/21 at 10:00 PM, Licensing Program Analyst (LPA) Cheng conducted a Case Management visit to conduct facility's Comp III presentation. LPA met with Licensees Karen & Michael Warner and explained reason for visit.

LPA conducted Comp III visit with Karen & Michael Warner.

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)
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