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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002917
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:22:03 PM

Document Has Been Signed on 10/19/2022 12:22 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:KIMBERLY'S FAMILY HOMEFACILITY NUMBER:
585002917
ADMINISTRATOR:KENNEDY, KIMBERLYFACILITY TYPE:
735
ADDRESS:1907 8TH AVETELEPHONE:
(530) 301-7820
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 4CENSUS: 4DATE:
10/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Kimberly KennedyTIME COMPLETED:
12:30 PM
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LPA Hiratsuka, conducted this unannounced pre-licensing visit. LPA wore a surgical mask during visit and observed staff wearing a mask. This facility is undergoing a change of ownership.

This main entrance opens to the main sitting room. The kitchen, nook, and office with a full bathroom are to the right of the main entrance. There is a staff bedroom next to the nook area. There is a hallway that leads to the back of the facility. The hallway leads to four private resident rooms and one sitting area. The sitting area has a full bathroom. There is an exit in the sitting are as well. The backyard has a shed in one corner.


Several topics were discussed.

Component III orientation was conducted.


This facility meets regulations. LPA is going to submit this report to the application specialist.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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