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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004560
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:25:05 PM

Document Has Been Signed on 05/05/2023 01:25 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:
05/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Program Director Nati MaugaTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan conducted an unannounced case management visit on 05/05/2023. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPAs met with Program Director Nati Mauga and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 05/05/2023 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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