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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 587003700
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:13:22 PM

Document Has Been Signed on 10/18/2023 04:13 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 CAREFACILITY NUMBER:
587003700
ADMINISTRATOR:GUANZON, LORENAFACILITY TYPE:
735
ADDRESS:5546 TRAILHEAD LOOPTELEPHONE:
(530) 751-7532
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 6CENSUS: 4DATE:
10/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Lorena GuanzonTIME COMPLETED:
04:20 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with the caregiver.

The main entrance opens into a small common area on the left and a the kitchen and main common are to the right. There is a hallway to the left of the main entrance that leads to three shared resident rooms; one staff room that has a full private bathroom; a full common bathroom; and a laundry room that has a door to the garage. The main common area has a sliding door to the backyard. The gate is on the same side as the garage. There are locked cabinets for cleaning toxins and medications.

Four resident files were reviewed
Two staff files were reviewed.

The following shall be updated and submitted to Community Care Licensing by 11/01/2023:
-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: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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