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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920104
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:23:49 PM

Document Has Been Signed on 03/11/2025 03:23 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:MARIPOSAFACILITY NUMBER:
045920104
ADMINISTRATOR/
DIRECTOR:
LEAK, TAMRAFACILITY TYPE:
740
ADDRESS:1073 RAVEN LANETELEPHONE:
(530) 200-2909
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY: 4CENSUS: 3DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Tamra Leak - licensee / administratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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03/04/2025 12:30 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with licensee / administrator Tamra Leak ( admin. cert # 7034229740 exp. 07/28/2025) and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. Medications were reviewed. Medication is locked in a cabinet.

The facility provides recreational activities for the residents according to their preferences and abilities. All residents attend day programs. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged. Smoke detectors are all operational. No pools/bodies of water are on premises. Last emergency evacuation drill was conducted in September 2024, which was a flood drill, the facility has been conducting fire drills monthly.

LPA requested the following documents that need to be updated in the facility file: LIC500 Personnel Report.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was provided to licensee / administrator Tamra Leak,

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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