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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700744
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:29:48 AM

Document Has Been Signed on 01/21/2025 11:29 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:SEQUOIA HOUSEFACILITY NUMBER:
092700744
ADMINISTRATOR/
DIRECTOR:
GILLMOR, TYLERFACILITY TYPE:
735
ADDRESS:3025 GLEE LNTELEPHONE:
(530) 644-2412
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY: 6CENSUS: 5DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Tyler GillmorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Lavinia Muscan arrived unannounced on 01/21/25 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA and Administrator Tyler Gillmor toured the facility together to ensure the health and safety of clients in care. The areas toured included resident rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. The disaster drill is current. The administrator's certificate is current. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguishers are ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed.

LPA reviewed resident (3) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills. Staff training contained the required initial training.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.

Exit interview conducted. A copy of this report was printed and given to Administrator.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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