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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 581302894
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:07:19 PM

Document Has Been Signed on 09/28/2023 01:07 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: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: 31DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jessica BurwellTIME COMPLETED:
01:17 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured with Caregiver Tina Daughter, and House Manager Jessica Burwell the visit with LPA.

This facility has three buildings for residents. The main building has ten rooms that are shared, the main common areas, food storage, kitchen, and dining areas. A second building in the back has three client rooms that are shared and two private rooms, and the third building for residents has two resident rooms which are shared. In the main building some resident rooms have private full bathrooms, several common full bathrooms, locked cabinets and closets for records, cleaning chemicals, and medications. The other buildings have full bathrooms for the residents. There is a separate building for laundry.

Resident and staff records were reviewed.

A couple of topics were discussed.

The following shall be updated and submitted to Community Care Licensing by 10/15/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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