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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002992
Report Date: 04/15/2024
Date Signed: 06/17/2024 11:19:36 AM

Document Has Been Signed on 06/17/2024 11:19 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:NELSON GREEN FAMILY HOMEFACILITY NUMBER:
315002992
ADMINISTRATOR/
DIRECTOR:		GREEN, LINFACILITY TYPE:
735
ADDRESS:12475 NELSON DRIVETELEPHONE:
(925) 791-8184
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 4CENSUS: 4DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Lin GreenTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 4/15/2024 LPA Tryon visited the facility to conduct an annual visit. LPA met with licensee Lin Green.

LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, food storage, yard. Smoke detectors installed, carbon monoxide detector installed. Fire extinguishers present and charged. The facility is clean and well-furnished. Bathrooms have recently been renovated and are nice and new with new walls, floors, plumbing/fixtures. Kitchen has been fixed up. Food supplies are appropriate to meet 2 days perishable and 7 days non-perishable.
Medications are centrally stored and locked. Cleaners and other potentially hazardous materials are secured.
LPA reviewed the CARE Tool with staff.

LPA reviewed 2 staff files and 2 resident files. Files include required information.

At this time the home appears to be in substantial compliance with regulations.
No deficiencies were cited at this visit. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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