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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002813
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:57:00 PM

Document Has Been Signed on 09/23/2024 03:57 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/
DIRECTOR:		WARNER, KARENFACILITY TYPE:
735
ADDRESS:1122 H ST.TELEPHONE:
(530) 870-8504
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Karen WarnerTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analysts (LPAs) Graham Gunby and Kerry Hiratsuka arrived on Monday September 23, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed client (2) and staff (2) files. All client files contained the required paperwork. All staff files contained the required paperwork and training.

LPA Gunby and Administrator Karen toured the facility together to ensure the health and safety of clients in care. The areas toured included bedrooms, common areas, kitchen, bathrooms, laundry room, front yard and backyard. All chemicals and toxins were kept locked and inaccessible to clients. Facility has (3) fire extinguishers (one in the living room, by the front door, in the backyard). In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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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