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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581302894
Report Date: 10/19/2022
Date Signed: 10/19/2022 09:32:54 AM

Document Has Been Signed on 10/19/2022 09:32 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:FEATHER RIVER MANORFACILITY NUMBER:
581302894
ADMINISTRATOR:TERRY, NORAFACILITY TYPE:
740
ADDRESS:3962 WEST ELLA AVE.TELEPHONE:
(530) 743-5022
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY: 32CENSUS: DATE:
10/19/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Jessica BurwellTIME COMPLETED:
09:40 AM
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LPA Hiratsuka, conducted this unannounced visit. LPA wore the surgical mask during this visit.

The purpose of this visit was to go over the documents that are required for resident files and staff files. This was a continuation from the first annual inspection last week. Administrator Scott Terry was unavailable this morning to review the files with LPA. LPA did leave behind some documents that are required for staff and resident files with Caregiver.

LPA shall return at a later date.

No deficiencies cited during this visit.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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