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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004560
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:50:27 PM

Document Has Been Signed on 04/27/2023 02:50 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:REACH ADULT DEVELOPMENT SITE #5FACILITY NUMBER:
317004560
ADMINISTRATOR:SUH, SEANFACILITY TYPE:
775
ADDRESS:9980 NIBLICK DRTELEPHONE:
(916) 778-8696
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 45CENSUS: 15DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Orlando Perez, Program DirectorTIME COMPLETED:
02:45 PM
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On 04/27/2023 at 1pm, LPA Ryan Ayers and LPM Laura Munoz arrived unannounced at the facility to conduct an Annual Inspection. Program Director (PD), Orlando Perez, greeted LPA Ayers and LPM Munoz at the front door and LPA Ayers explained the nature of the visit. PD Perez offered LPA Ayers and LPM Munoz a tour of the facility. Census was 15 clients and 6 staff plus PD.

LPA Ayers and LPM Munoz toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathroom, kitchen, and outside yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA, LPM, and PD covered the infection control topics and facility was found to be in substantial compliance at this time. Water temp was 107 degrees.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Ryan Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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