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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 181370671
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:37:51 PM

Document Has Been Signed on 04/19/2023 02:37 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MOUNTAIN JEWELS HOMEFACILITY NUMBER:
181370671
ADMINISTRATOR:HOFFMAN, MARIEFACILITY TYPE:
735
ADDRESS:527-960 LITTLE VALLEY RD.TELEPHONE:
(530) 336-6987
CITY:MCARTHURSTATE: CAZIP CODE:
96056
CAPACITY: 10CENSUS: 5DATE:
04/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Marie HoffmanTIME COMPLETED:
02:47 PM
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Kerry Hiratsuka and Sarah Benson, Licensing Program Analysts (LPAs) met with Marie and Bob Hoffman for required annual visit.

There are two buildings on this property that house the residents. Of the two, only one is in use at this at this time due to the current census. LPAs toured both buildings. LPAs also toured the facility property and there are multiple buildings on this property. Some of the buildings the residents have access to and some they don't. No health and safety issues were observed.


Two resident files were reviewed.

Multiple topics discussed.

No deficiencies cited.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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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