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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002322
Report Date: 04/27/2023
Date Signed: 04/28/2023 12:14:46 PM


Document Has Been Signed on 04/28/2023 12:14 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:WESTWOOD HILLS SENIOR CARE HOMEFACILITY NUMBER:
315002322
ADMINISTRATOR:LISNAWATI, SHAINAFACILITY TYPE:
740
ADDRESS:521 SILKWOOD DRIVETELEPHONE:
(530) 210-6183
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Francisca IngegneriTIME COMPLETED:
11:30 AM
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On 4/27/2023 LPA Tryon visited the facility to conduct an annual visit using the CARE Tool. LPA met with Shaina Lisnawati and Francisca Ingegneri.

LPA toured the facility including common areas, dining area, bedrooms, bathrooms, laundry room, kitchen, and Yard.

The home appears to be well-furnished, clean, and in good repair. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies and of good quality and variety. The facility has adequate supplies of PPE, cleaners, etc. Smoke detectors installed and functioning, fire extinguisher present and charged, carbon monoxide detector installed.

LPA attempted to review the CARE Tool with staff. However, the tool would not function during the visit. Therefore, LPA will return at a later date to complete the inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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