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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
312700283
Report Date:
10/25/2023
Date Signed:
10/25/2023 03:14:12 PM
Document Has Been Signed on
10/25/2023 03:14 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
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
HARMONY HOUSE
FACILITY NUMBER:
312700283
ADMINISTRATOR:
PORTILLO, ERIKA
FACILITY TYPE:
735
ADDRESS:
11080 B AVENUE
TELEPHONE:
(530) 886-3470
CITY:
AUBURN
STATE:
CA
ZIP CODE:
95603
CAPACITY:
20
CENSUS:
20
DATE:
10/25/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:05 PM
MET WITH:
Brandon Wautlet
TIME COMPLETED:
03:06 PM
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On 10/25/23 LPA Tryon visited the facility to do a quick inspection related to the recent new fire clearance. The facility has requested an increase from 20 beds to 28.
LPA toured the facility to ensure that the facility sketch of the physical plant matches the actual building. LPA found that the sketch of the building is accurate.
The fire department has approved a new fire clearance for 28 residents on 10/19/2023.
Changes will be made to reflect the increased capacity.
Exit interview conducted.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Todd Tryon
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
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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