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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097003223
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:01:44 PM


Document Has Been Signed on 10/16/2023 04:01 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:PINE TREE VILLAFACILITY NUMBER:
097003223
ADMINISTRATOR:LYNN RELOZAFACILITY TYPE:
740
ADDRESS:3353 CIMMARRON ROADTELEPHONE:
(530) 672-9080
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:15CENSUS: 10DATE:
10/16/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Caregiver John MabbaguTIME COMPLETED:
04:15 PM
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LPA Lavinia Muscan, arrived to conduct a health and safety check in response to being notified the licensee passed away on 10/15/23. Today, LPA checked the food supply, staff training, and did a brief walk through. No concerns noted. Residents emergency information and 602's obtained.

-The following below is required for an Emergency Approval to Operate:
Documents required for Emergency Approval to Operate (LIC9117) if a family member is seeking to apply for a change of ownership.
LIC 200
Evidence of control of property- provide proof
Application Fee
Administrator Certificate
LIC 500
LIC 999
Copy of a death certificate- submit to licensing upon receipt
Attend the next orientation
The department shall decide within 60 days after the application is submitted whether to issue a provisional license. A provisional license shall be granted only if the department is satisfied that the conditions specified in subdivision (a) have been met and that the health and safety of the residents of the facility will not be jeopardized.

A meeting is currently being scheduled between Community Care Licensing and Administrator.

No citations were cited during today's visit.

Exit interview conducted. Copy of report left at facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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