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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 090312052
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:30:48 PM

Document Has Been Signed on 03/27/2023 01:30 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MOTHER LODE REHABILITATIONFACILITY NUMBER:
090312052
ADMINISTRATOR:DAVIES, SUSIEFACILITY TYPE:
775
ADDRESS:399 PLACERVILLE DRIVETELEPHONE:
(530) 622-4848
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY: 250CENSUS: 54DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Susie DaviesTIME COMPLETED:
01:40 PM
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On March 27. 2023 Licensing Program Analysts (LPAs) Lavinia Muscan and Melissa Parks, arrived at the facility unannounced to conduct an annual visit. LPAs met with Facility Administrator Susie Davies and explained the purpose of the visit. The following Personal Protective Equipment (PPE) was worn: surgical mask and N95. Additionally, LPAs were screened by front desk. All staff and clients were observed wearing a mask or face shield.

LPAs and Administrator toured facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: bathrooms, classrooms, hallways, kitchen including walk-in refrigerator and freezer, and outside grounds.. LPAs reviewed 5 client files and 6 staff files. All files contained the required paperwork. Water temperatures were within the required temperature range. Facility had a full supply of PPE including surgical masks, face shields, gowns, and N95s. First Aid kit was fully stocked. All cleaning chemicals and laundry supplies were kept locked.

Administrator agreed to send updated LIC500 and LIC610. LPAs obtained a copy of the facility's current mitigation plan.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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