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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
292700174
Report Date:
01/11/2024
Date Signed:
01/11/2024 09:31:05 AM
Document Has Been Signed on
01/11/2024 09:31 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:
BRUNSWICK VILLAGE
FACILITY NUMBER:
292700174
ADMINISTRATOR:
LAINE, KRISTIE
FACILITY TYPE:
740
ADDRESS:
316 OLYMPIA PARK CIRCLE
TELEPHONE:
(530) 274-1992
CITY:
GRASS VALLEY
STATE:
CA
ZIP CODE:
95945
CAPACITY:
100
CENSUS:
DATE:
01/11/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Kristie Laine
TIME COMPLETED:
09:35 AM
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LPA Hiratsuka conducted this visit to deliver an amended report for complaint #59-AS-20231109113548
, that was delivered on 11/30/2023. The findings of unfounded has not changed.
No deficiencies cited.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
01/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/11/2024
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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