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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 090312052
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:55:14 AM

Document Has Been Signed on 04/15/2024 11:55 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MOTHER LODE REHABILITATIONFACILITY NUMBER:
090312052
ADMINISTRATOR/
DIRECTOR:		DAVIES, SUSIEFACILITY TYPE:
775
ADDRESS:399 PLACERVILLE DRIVETELEPHONE:
(530) 622-4848
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY: 250CENSUS: 68DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator Susie DaviesTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On 4/15/24 Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to conduct an annual visit. LPA met with Facility Administrator Susie Davies and explained the purpose of the visit.

LPA 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 and outside grounds.. LPA reviewed 5 client files and 5 staff files. All files contained the required paperwork. Fire drills reviewed. First Aid kit was fully stocked. All cleaning chemicals and laundry supplies were kept locked. Fire extinguisher is ready for use.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month.

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

Exit interview conducted and copy of report was emailed to Administrator.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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