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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097003223
Report Date: 12/04/2023
Date Signed: 12/04/2023 12:52:20 PM


Document Has Been Signed on 12/04/2023 12:52 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: 11DATE:
12/04/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Lynn RelozaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Talwinder Bains ,arrived unannounced on 12/04/23 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 , did a brief walk through inside and outside the facility with administrator. No concerns noted.

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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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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