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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700046
Report Date: 04/06/2023
Date Signed: 04/07/2023 10:27:10 AM


Document Has Been Signed on 04/07/2023 10:27 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:SHOCKLEY WOODS LOVING HEARTSFACILITY NUMBER:
312700046
ADMINISTRATOR:MAGUREAN, TATIANAFACILITY TYPE:
740
ADDRESS:12719 SHOCKLEY WOODS CTTELEPHONE:
(916) 844-4330
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 3DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosan WrightTIME COMPLETED:
05:00 PM
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On 4/6/2023 LPA Tryon visited the facility to do an annual review. LPA met with staff Rosan Wright.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, garage, storage, yard. The home is in nice condition, well-kept and nicely furnished.
Food supplies are appropriate to meet the requirement of 7 days non-perishable and 2 days perishable. Medications are centrally stored, locked and labeled. Home has adequate supply of cleaners and household goods; potentially dangerous items are secured.
Bathrooms have non-skid surfaces in showers, grab bars, plumbing fixtures are in good condition and work properly.
LPA reviewed the RCFE CARE Tool with staff. Staff and resident files have required documents.
Smoke and carbon monoxide detectors installed and functioning.
Activities such as video and games present.
Appropriate postings present regarding reporting abuse, COVID posters, rights, evacuation routes, etc.

At this time the facility appears to be in substantial compliance. No deficiencies were cited at this visit.
Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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