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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
052701102
Report Date:
01/27/2023
Date Signed:
01/27/2023 10:43:41 AM
COMPREHENSIVE INSPECTION
Document Has Been Signed on
01/27/2023 10:43 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
SACRAMENTO AC/SC
,
2525 NATOMAS PARK DR. STE.270
SACRAMENTO
,
CA
95833
FACILITY NAME:
FOOTHILL LIVING CARE HOME
FACILITY NUMBER:
052701102
ADMINISTRATOR:
NGUYEN, ROSAURORA
FACILITY TYPE:
735
ADDRESS:
8269 SPARROWK ROAD
TELEPHONE:
(209) 341-9680
CITY:
VALLEY SPRINGS
STATE:
CA
ZIP CODE:
95252
CAPACITY:
4
CENSUS:
DATE:
01/27/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
TIME COMPLETED:
11:00 AM
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LPA Lewis attempted to conduct the required 1 year visit. The facility is not open and has no residents at this time. LPA spoke with licensee and they stated that they are currently waiting for VMRC.
SUPERVISORS NAME
:
Liza King
LICENSING EVALUATOR NAME
:
Kesha Lewis
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/27/2023
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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