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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002923
Report Date: 10/05/2022
Date Signed: 10/05/2022 12:09:29 PM

Document Has Been Signed on 10/05/2022 12:09 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:MARYSVILLE-YUBA CARE HOME #1FACILITY NUMBER:
585002923
ADMINISTRATOR:VALENZUELA LOPEZ, BENITAFACILITY TYPE:
735
ADDRESS:5744 KIRKHILL DRTELEPHONE:
(530) 701-4037
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 0DATE:
10/05/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Benita Velenzuela Lopez and Cindy MunozTIME COMPLETED:
12:15 PM
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LPA Hiratsuka, conducted this announced prelicensing visit. LPA met with Applicants Benita Velenzuela Lopez and Cindy Munoz.

This facility has a fire clearance for three ambulatory and one non-ambulatory residents. The main entrance opens to a sitting area and small office area to the left. To the right is a wall that has a door leading to the garage and a closet that is going to be locked. Past the sitting area in the back is the common area and the kitchen on the right. There is a locked cabinet for medications in the kitchen. On left side of the common area is the staff room that has a full private bathroom. To the right of the kitchen is a hallway leading to the four private resident rooms. There is one full common bathroom. There is one full bathroom that is shared by two resident rooms. There is a sliding door leading to the backyard from the back common room. There is a shed in the backyard. There is a gate on the same side as the garage. The garage is going to be used for storage.

Component III orientation is waived by LPA because the applicants operate other facilities.

Multiple topics were discussed.

This facility meets the 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: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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