<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005092
Report Date: 08/19/2024
Date Signed: 08/19/2024 04:57:37 PM


Document Has Been Signed on 08/19/2024 04:57 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 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: 14DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Therese Lancaster, Andrea LancasterTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/19/2024, Licensing Program Analyst Todd Tryon arrived at the facility unannounced to conduct a required Annual Inspection. LPA met with Facility Administrator, Andrea Lancaster and Licensee Therese Lancaster

LPA, Licensee and Administrator toured facility together to ensure health and safety of residents in care. Areas toured included: common areas, resident bedrooms, backyard, restrooms, hallways, offices, kitchen, food storage areas. LPA found 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. LPA observed three (3) fire extinguishers which were charged and checked annually. Smoke detector/carbon monoxide detector/fire alarm system installed. System is professionally inspected annually.

LPA noted no immediate health, safety, or personal rights violations.

LPA reviewed a total of (3) resident files and (3) staff files.

LPA reviewed the CARE Tool with licensee.

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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1