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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
585002923
Report Date:
11/14/2024
Date Signed:
11/14/2024 10:41:47 AM
Document Has Been Signed on
11/14/2024 10:41 AM
- 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 #1
FACILITY NUMBER:
585002923
ADMINISTRATOR/
DIRECTOR:
VALENZUELA LOPEZ, BENITA
FACILITY TYPE:
735
ADDRESS:
5744 KIRKHILL DR
TELEPHONE:
(530) 701-4037
CITY:
MARYSVILLE
STATE:
CA
ZIP CODE:
95901
CAPACITY:
5
CENSUS:
4
DATE:
11/14/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:
Benita Valenzuela Lopez
TIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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LPA Hiratsuka conducted this unannounced annual visit. Administrator Lopez arrived during visit. Two caregivers were on duty when LPA arrived.
Licensee increased capacity this year to five residents. This facility has a fire clearance for four 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 a resident room with 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 the end of the month
-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:
11/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
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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