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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920086
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:11:16 PM

Document Has Been Signed on 04/18/2024 12:11 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:AUBURN VALLEY ADULT CARE INC.FACILITY NUMBER:
315920086
ADMINISTRATOR/
DIRECTOR:
CIRIC, NATHANFACILITY TYPE:
735
ADDRESS:9865 HUBBARD RD.TELEPHONE:
(916) 613-1710
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 3CENSUS: 0DATE:
04/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nathan CiricTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 4/18/2024 LPA Tryon visited the facility to do a prelicensing visit. LPA met with applicant Nathan Ciric.
LPA toured the home including common areas, kitchen, dining area, bedrooms, bathrooms, hallway, food storage, yard, laundry. The home is brand new with all new furnishings, is nicely decorated and spacious. Smoke detectors installed and functioning, carbon monoxide detector installed, fire extinguishers present and charged. Rooms are furnished with basic required furniture such as bed, night stand, lights, drawers, etc. The yard is large and has a metal fence around the yard with a gate that will close across the driveway. The outside has plenty of area for activities, a large enclosed patio on one side of the house. The facility has appropriate postings of personal rights, house rules, posters of agencies to contact with complaints/concerns, emergency plan, menu, activities, etc. There is a locked storage cabinet for medications in the kitchen, knives/other sharp objects are locked in the kitchen, cleaners/chemicals locked separately from food. Food supplies look appropriate at this time.

LPA reviewed the CARE Tool with applicant.

LPA reviewed the Adult Residential Facility Orientation Component III with Mr. Ciric.

At this time the home appears to meet Title 22 Regulations. Applicant has completed ARF Orientation Comp III.


SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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