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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005092
Report Date: 08/21/2023
Date Signed: 08/21/2023 11:48:19 AM


Document Has Been Signed on 08/21/2023 11:48 AM - 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 CREEKSIDE VILLAFACILITY NUMBER:
317005092
ADMINISTRATOR:LANCASTER, THERESE M.FACILITY TYPE:
740
ADDRESS:695 DAIRY ROADTELEPHONE:
(530) 823-5273
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:15CENSUS: 13DATE:
08/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Administrator Andrea Lancaster TIME COMPLETED:
12:00 PM
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On 08/21/2023, Licensing Program Analysts (LPA's) Jaynae Boyles and John Tryon arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPAs met with Facility Administrator, Andrea Lancaster and explained the purpose of the visit.

LPAs Boyles, Tryon and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms,backyard, and common restrooms. LPA's observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured at 118 F. LPA's observed three (3) fire extinguishers which are in need of servicing and the Administrator scheduled an appointment for todays date to ensure they are serviced.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) residents' files and four (4) staff files.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2023
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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