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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002944
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:34:55 PM

Document Has Been Signed on 05/22/2024 04:34 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:IMAGINE FUNCTIONAL LIVING SKILLS PROGRAM, LLCFACILITY NUMBER:
315002944
ADMINISTRATOR/
DIRECTOR:		PITZ, NICCOLEFACILITY TYPE:
775
ADDRESS:11960 HERITAGE OAK PL. STE 19TELEPHONE:
(530) 537-2364
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 30CENSUS: 10DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Niccole PitzTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 5/22/24 LPA Tryon visited the program to do an annual review of the day program. LPA met with Niccole Pitz.

The program has been running for a year now, and appears to be doing well. The average daily attendance is about 12 participants. The program has clients participate in various activities both at the center and in the community, depending on client choices and needs at the time. The program is largely client-driven.

LPA toured the program. The program has a nicely decorated entry room with furniture to sit and relax, exercise equipment, some vegetable plants in a unique vertical planter to allow participants some experience with gardening.

There is also a large classroom-type area with TV/video equipment and other learning materials; and another large room with tables where participants eat lunch and participate in nutrition type activities.

There is also a back storage room, staff office area and restrooms.

LPA reviewed the CARE Tool with Ms. Pitz. LPA reviewed 2 client files and 2 staff files. Staff receive ongoing training in various subjects and areas related to working with participants.

Potentially hazardous items and substances are secured in storage areas. No hazards were noted. The program is neatly set up and clean, nicely furnished.

At this time, the program appears to be in substantial compliance with regulations, No deficiencies were cited. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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