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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002813
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:06:31 PM

Document Has Been Signed on 09/06/2023 04:06 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Karen WarnerTIME COMPLETED:
04:15 PM
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LPA Hiratsuka conducted this unannounced annual inspection. LPA toured with Administrator Karen Warner.

This facility has four private resident rooms and one staff room. There are two full common bathrooms, laundry room, and a staff room. There is a kitchen and dining room. There is a ramp in the backyard that leads from the house to the yard. There is a shed in the backyard. There is an ample supply of perishable and nonperishable food supply. No health and safety issues were observed.

The following shall be updated and submitted to Community Care Licensing Division by September 25, 2023:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-LIC 610 emergency disaster plan.

No deficiencies were observed.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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