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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 587003428
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:06:39 PM

Document Has Been Signed on 08/30/2023 03:06 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:GUANZON RESIDENTIAL CARE 2FACILITY NUMBER:
587003428
ADMINISTRATOR:GUANZON, LORENAFACILITY TYPE:
735
ADDRESS:1727 SHORELINE DRIVETELEPHONE:
(530) 751-7532
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 6CENSUS: 6DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Lorena GuanzonTIME COMPLETED:
03:15 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Licensee/Administrator Lorena Guanzon.

This facility has three shared resident rooms and one staff room. The staff room has a full private bathroom. There is one full common bathroom. The main entrance opens to a sitting area and in the back of the facility is another sitting area along with dining and kitchen. There is a laundry room that leads to the garage. All areas toured did not have any health and safety concerns.

LPA and Licensee spent time working on the staff rosters for all three of the facilities the licensee owns.

A couple of topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by September 15, 2023:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-LIC 610 emergency disaster plan.

No deficiencies were observed.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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