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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920104
Report Date: 04/23/2024
Date Signed: 04/23/2024 11:39:59 AM

Document Has Been Signed on 04/23/2024 11:39 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:MARIPOSAFACILITY NUMBER:
045920104
ADMINISTRATOR/
DIRECTOR:		LEAK, TAMRAFACILITY TYPE:
740
ADDRESS:1073 RAVEN LANETELEPHONE:
(530) 200-2909
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY: 4CENSUS: 0DATE:
04/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Administrator- Tamra Leak TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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
On 04/23/2024, Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility announced to conduct a Pre licensing Inspection. LPA met with Facility Administrator, Tamra Leak and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure that the facility is ready to take its first clients. Areas toured include but are not limited to: common areas, bedrooms, garage, backyard, and restrooms. LPA observed the facility to be clean, in good repair and odor-free.

LPA observed bedrooms to have all the required furnishings, working lights and windows with screen. LPA observed bathrooms to have necessary grab bars and trash cans with lids.

Component III was conducted during this inspection.

This facility is ready to be licensed.

Exit interview conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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