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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700214
Report Date: 12/16/2024
Date Signed: 12/16/2024 02:26:58 PM

Document Has Been Signed on 12/16/2024 02:26 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:WILSON HOME, THEFACILITY NUMBER:
092700214
ADMINISTRATOR/
DIRECTOR:		JESSICCA WILSONFACILITY TYPE:
735
ADDRESS:4310 OAK VIEW DRIVETELEPHONE:
(530) 363-2631
CITY:PILOT HILLSTATE: CAZIP CODE:
95664
CAPACITY: 6CENSUS: 0DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Elliot Wilson, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 12/16/2024 LPA met with Elliot Wilson at the facility. At this time, the facility residents are in Hawaii at the licensee's home there. The hope is to become licensed in Hawaii, and the residence of the consumers will be moved there permanently. At this time, the licensee is in California for a few days. LPA toured the house including common areas, kitchen, bedrooms, bathrooms, laundry, storage, yard etc. At the moment no one is staying at the facility, however, the house is still fully furnished.
There are smoke and carbon monoxide detectors installed, as well as fire extinguisher.

LPA reviewed the CARE Tool with licensee. There were no residents or other staff present to interview. LPA reviewed staff files including Admin. Certificate, First Aid, etc.

At this time no deficiencies were cited. The owners are working on licensing their home in Hawaii. At the point that the home in Hawaii is licensed, the owners will probably sell the Pilot Hill Home.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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