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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295002148
Report Date: 06/24/2024
Date Signed: 06/26/2024 09:11:04 AM


Document Has Been Signed on 06/26/2024 09:11 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:LAKE WILDWOOD MANORFACILITY NUMBER:
295002148
ADMINISTRATOR:LOVE, MARY VBFACILITY TYPE:
740
ADDRESS:17802 SILVER PINE DRIVETELEPHONE:
(530) 432-7788
CITY:PENN VALLEYSTATE: CAZIP CODE:
95946
CAPACITY:6CENSUS: 1DATE:
06/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mary Love, licenseeTIME COMPLETED:
04:00 PM
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LPA Tryon arrived at the facility to do an unscheduled annual visit. LPA was greeted by staff Danny, who contacted licensee Mary Love. She arrived a short time later.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, laundry, storage, outside area.

The house is clean, nicely furnished, has appropriate furnishings as per the regulations. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies, appear to be of good quality.
The facility has medications centrally stored and locked.
Facility has adequate supplies of cleaners, hygiene products, PPE, etc.
No hazards are noted.
Smoke detectors are functional, carbon monoxide detector installed, fire extinguishers present and charged.
Land line phone available.
Bedrooms have appropriate furnishings, bedding, etc.

LPA reviewed the CARE Tool with licensee. Emergency and disaster plans available, Infection control plan etc.
LPA reviewed 2 staff files and one resident file.

At this time , the home appears to be in substantial compliance with the regulations. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
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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