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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002992
Report Date: 12/28/2023
Date Signed: 12/29/2023 02:41:58 PM

Document Has Been Signed on 12/29/2023 02:41 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: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: DATE:
12/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:N/ATIME COMPLETED:
12:00 PM
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On 12/28/2023 LPA Tryon attempted to do a case management visit to the care home to follow up on concerns raised by a recent Regional Center visit/evaluation.

Upon arrival, LPA saw a work truck at the facility, and there was clearly some construction work taking place. LPA met and spoke with the landlord for the facility, who said he is working on re-doing a bathroom at this time. The Administrator and residents had left a while before I arrived.

It appears that the home is following up with some of the concerns raised by RC.

LPA will return at a time next week to check on progress and look into the issues further.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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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