<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 587004202
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:31:04 PM


Document Has Been Signed on 01/19/2023 03:31 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:COMFORT CARE ELDERLY HOMEFACILITY NUMBER:
587004202
ADMINISTRATOR:USVAT, SIMONAFACILITY TYPE:
740
ADDRESS:4205 MARY AVENUETELEPHONE:
(530) 749-9543
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY:6CENSUS: 1DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Simona UsvatTIME COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing them.

The main entrance opens to a common area. To the left of the main entrance is a hallway that leads to the licensee's living area. To the right of the main entrance is the kitchen and dining area. There is a hallway on the right side that leads to three resident rooms and one full common bathroom.


Several topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1