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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
585920218
Report Date:
10/02/2024
Date Signed:
10/02/2024 10:17:52 AM
Document Has Been Signed on
10/02/2024 10:17 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:
YUBA-MARYSVILLE CARE HOME
FACILITY NUMBER:
585920218
ADMINISTRATOR/
DIRECTOR:
VALENZUELA, BENITA
FACILITY TYPE:
735
ADDRESS:
5703 MEADOW BROOK WAY
TELEPHONE:
(530) 701-4037
CITY:
MARYSVILLE
STATE:
CA
ZIP CODE:
95901
CAPACITY:
4
CENSUS:
0
DATE:
10/02/2024
TYPE OF VISIT:
Prelicensing
ANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:
Benita Valenzuela Lopez
TIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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LPA Hiratsuka conducted this announced prelicensing visit. LPA met with Applicant Benita Valenzuela Lopez.
This facility has a fire clearance for three ambulatory and one non-ambulatory. This facility has a four private resident rooms. None of the resident rooms have exits to the outside. There is a staff room that has an exit to the outside and a full private bathroom. There is one full common bathroom. There are two sitting areas and kitchen. There is a door leading to the garage from the laundry room. The backyard was inspected. There is a gate on the same side as the garage.
LPA waived Component III Orientation because Applicant operates several facilities.
This facility meets regulations. LPA is going to submit this report to the application specialist for their review.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/02/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/02/2024
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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