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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618209
Report Date: 10/11/2022
Date Signed: 10/11/2022 09:23:40 AM


Document Has Been Signed on 10/11/2022 09:23 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:AVILA, GLIDAFACILITY NUMBER:
343618209
ADMINISTRATOR:AVILA, GLIDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 420-5871
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:14CENSUS: 12DATE:
10/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Glida AvilaTIME COMPLETED:
09:30 AM
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Licensing Program Manager Natalie Dunaway (LPM) and Licensing Program Analyst Jennifer Velasco (LPA) conducted a case management visit to deliver an Immediate Exclusion Order. The exclusion resulted from an incident at an off-site location; the incident did not involve the facility.

The individual is not present, employed, or residing at the facility.

An exit interview was conducted with L1. A notice of site visit was provided and must remain posted for 30 days. Licensee was provided with LIC 995B.

No Title 22 Deficiencies were cited during the visit.
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: 707-953-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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