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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003007
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:39:09 PM


Document Has Been Signed on 03/10/2023 03:39 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:DAD'S PLACE INCFACILITY NUMBER:
315003007
ADMINISTRATOR:MURRAY, KATHERINE SFACILITY TYPE:
740
ADDRESS:1220 LIVE OAK LANETELEPHONE:
(530) 718-0932
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 0DATE:
03/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Katherine MurrayTIME COMPLETED:
04:00 PM
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On 3/10/2023 LPA Tryon visited the facility to conduct a pre-licensing visit and a Component III RCFE Orientation.
LPA met with applicant Katherine Murray.
LPA toured the house including common areas, kitchen, bedrooms, hallways, bathrooms, storage areas, laundry, yard. The facility is nicely furnished, clean and in good condition. Rooms are spacious and nicely and uniquely decorated. Locked storage present for medications, cleaners, laundry products, etc. The facility has a refrigerator in a locked cabinet if needed for medications. Facility has washer/dryer and laundry supplies. There are smoke detectors appropriately installed in required areas. There are 3 carbon monoxide detectors. The facility has a functioning call system for each resident that rings to central locations and notifies of individuals calling for assistance.
LPA reviewed facility files and the facility has appropriate resident and staff documentation; and has access to CCL forms on-line.
Yard appears well-maintained and no hazards noted. There is adequate space available for activities both inside and outside. The facility has a supply of activities, and has a piano in the living room for entertainment purposes.
There is one bedroom that is very large and includes a kitchenette and private bath, that might be suitable for a couple or more independent residents. Facility is fire cleared for 5 non-ambulatory and 1 bedridden resident.
LPA reviewed the Component III RCFE Orientation with Ms. Murray.
At this time, the facility appears to be in substantial compliance; and the applicant has completed Comp III Orientation.
LPA will forward report to Central Applications to continue licensing process.
Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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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