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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002992
Report Date: 04/20/2023
Date Signed: 04/21/2023 08:46:27 AM

Document Has Been Signed on 04/21/2023 08:46 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:NELSON GREEN FAMILY HOMEFACILITY NUMBER:
315002992
ADMINISTRATOR:GREEN, LINFACILITY TYPE:
735
ADDRESS:12475 NELSON DRIVETELEPHONE:
(925) 791-8184
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 4CENSUS: 5DATE:
04/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lin GreenTIME COMPLETED:
04:00 PM
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On 4/20/2023 LPA Tryon visited the facility to do a prelicensing visit to the facility. LPA met with applicant LIn Green.
LPA toured the facility with Ms. Green, viewing common areas, kitchen, bedrooms, bathrooms, hallways, storage, laundry, medication storage, garage, yard. The facility appears to be in safe condition and clean. Hot water was tested and measured 110 degrees F, within regulation. Food supplies are more than adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Facility appears to be free of hazards.
Smoke detectors and carbon monoxide detectors installed. Medications are centrally stored and locked. First Aid supplies present.
LPA reviewed the prelicensing CARES tool with applicant.

The facility appears to be in substantial compliance with the regulations at this time.

LPA reviewed the Component III of the ARF Orientation with applicant.

Applicant has now completed Component III.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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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