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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 12:51:54 PM

Document Has Been Signed on 02/14/2022 12:51 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Susan and David CervantesTIME COMPLETED:
01:00 PM
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On 2/14/2022 LPA Tryon and LPA Muscan met with the applicants to conduct a RCFE Orientation Component III.

LPAs reviewed the Powerpoint presentation of the Comp III Orientation with the applicants, answered questions, etc.

At this time, the applicants have completed RCFE Orientation Component III.
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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