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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002844
Report Date: 02/14/2022
Date Signed: 02/14/2022 03:23:01 PM

Document Has Been Signed on 02/14/2022 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:COUNTRY SIDE HOME CAREFACILITY NUMBER:
315002844
ADMINISTRATOR:CERVANTES, SUSANFACILITY TYPE:
740
ADDRESS:2255 CENTRAL AVETELEPHONE:
(916) 402-4199
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 4DATE:
02/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Susan and David CervantesTIME COMPLETED:
01:00 PM
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LPA Tryon and LPA Muscan visited the facility on 2/14/2022 to conduct a pre-licensing visit. LPA met with applicants Susan and David Cervantes..
The facility is currently licensed under another licensee and has 4 residents.
LPAs toured the house including common areas, kitchen, bedrooms, bathrooms, hallways, laundry, yard, adjacent empty apartment, storage. The facility appears to be in substantial compliance at this time. The home is , clean,well-furnished and spacious. There is a good food supply including 2 days perishable and 7 days non-perishable food, dishes, supplies, utensils, furniture, bedding, linens/towels, etc. Smoke and carbon monoxide detectors are installed and functioning.

LPA reviewed the Inspection Tool pre-licensing section with applicants.

At this time, the facility appears to be in substantial compliance with the regulations.

Report will be forwarded to the Central Application Bureau to continue the licensing process.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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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