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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002813
Report Date: 10/13/2022
Date Signed: 10/13/2022 01:04:49 PM

Document Has Been Signed on 10/13/2022 01:04 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: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: 4DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Karen WarnerTIME COMPLETED:
01:15 PM
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
LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask. LPA observed staff wearing surgical masks.

This facility has a fire clearance for three ambulatory and one non-ambulatory residents. The main entrance opens to a sitting are to the right and an office on the left. Across is a hallway that leads to the kitchen and dining room on the left, two single bedroom on the left, a bathroom at the end, and a doorway on the left leading to a sitting area. The second sitting area has an exit to the backyard that has a ramp leading to the backyard. There are two single resident bedrooms on the right of the second sitting area. There is a laundry room on the right of the second sitting area that also has full bathroom. There is a driveway with a gate on the left side of the facility when facing the facility that leads to the backyard.

One staff and one resident file was reviewed during this visit.

Several topics were discussed during this visit.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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