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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002923
Report Date: 10/11/2023
Date Signed: 10/11/2023 02:09:32 PM

Document Has Been Signed on 10/11/2023 02:09 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 4DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Benita Valenzuela LopezTIME COMPLETED:
02:15 PM
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LPA Hiratsuka conducted this unannounced annual visit. Administrator Lopez and Licensee Bal, arrived during visit. Three caregivers were on duty when LPA arrived.

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.

Multiple topics were discussed.

The following shall be updated and submitted to Community Care Licensing by 10/30/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility


no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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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