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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001444
Report Date: 08/15/2023
Date Signed: 08/15/2023 11:30:32 AM


Document Has Been Signed on 08/15/2023 11:30 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:HIDDEN LAKE CARE HOMEFACILITY NUMBER:
315001444
ADMINISTRATOR:COPACIU, LYDIAFACILITY TYPE:
740
ADDRESS:8405 ACORN DRIVETELEPHONE:
(916) 303-3896
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 3DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Lydia CopaciuTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday August 15, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (3) and staff (2) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is complaint with fire drills.

LPA and Administrator Lydia toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, resident bathrooms, kitchen, garage,and backyard. LPA observed the facility's PPE supply. All water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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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