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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000496
Report Date: 08/12/2024
Date Signed: 08/12/2024 03:22:52 PM

Document Has Been Signed on 08/12/2024 03:22 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:C. SEISA HOUSE-STODDARDFACILITY NUMBER:
317000496
ADMINISTRATOR/
DIRECTOR:		SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:317 STODDARD WAYTELEPHONE:
(530) 889-0737
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 8/12/2024 LPA Tryon visited the facility to do an annual review. LPA met with caregivers Jenifer and Algren Balmeo. LPA also spoke with Administrator Chris Chu by phone. Licensee Joel Seisa was currently out of town.
LPA toured the house including common areas, kitchen, bedrooms, bathrooms, hallways, staff areas, yard. The facility appears to be clean and nicely furnished. Residents have appropriate furniture, bedding, etc. Smoke detectors are installed, as well as carbon monoxide detector. Fire extinguishers are present and charged.
Food supplies appear appropriate to meet requirement of 2 days perishable and 7 days non-perishable. Food appears to be varied and appetizing.
Bathrooms are clean, grab bars installed, paper towels and soap available, plumbing clean and functional.

LPA reviewed the CARE Tool with staff.
LPA reviewed 2 of 4 resident files, and 2 staff files. Files include required documentation.

Mr. Chu will forward copy of liability insurance to LPA.

At this time the facility appears to be in substantial compliance.
No deficiencies were cited at the visit.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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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