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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
312700054
Report Date:
04/04/2024
Date Signed:
04/04/2024 10:18:23 AM
Document Has Been Signed on
04/04/2024 10:18 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:
ADULT VOCATIONAL SERVICES INC
FACILITY NUMBER:
312700054
ADMINISTRATOR/
DIRECTOR:
SUH, SEAN
FACILITY TYPE:
775
ADDRESS:
3845 ATHERTON RD #7
TELEPHONE:
(916) 204-5726
CITY:
ROCKLIN
STATE:
CA
ZIP CODE:
95765
CAPACITY:
30
CENSUS:
23
DATE:
04/04/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:
Nati Mauga
TIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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LPA Hiratsuka conducted this unannounced annual visit.
This facility has a large front common room and a large common room in the back. There are two small classrooms. The back room is the main common area that has a sink and small cooking appliances for cooking classes. There are three restrooms. There are two exit doors to the outside in the front common room and there are two exit doors in the back. There are several areas that store supplies. There is an office in the front
Several client records and staff training records were reviewed.
Several topics were discussed.
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/04/2024
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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