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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 325000770
Report Date: 06/01/2023
Date Signed: 06/01/2023 03:19:54 PM

Document Has Been Signed on 06/01/2023 03:19 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:ALIVEFACILITY NUMBER:
325000770
ADMINISTRATOR:PILLER, MICHELEFACILITY TYPE:
775
ADDRESS:112 BUCHANAN STTELEPHONE:
(530) 283-0111
CITY:QUINCYSTATE: CAZIP CODE:
95971
CAPACITY: 30CENSUS: 30DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary McElwainTIME COMPLETED:
03:30 PM
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06/01/2023 01:00 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Mary McElwain Program Coordinator. Michele Piller is the Administrator. Certification is not posted at this time. (cert # exp.). Michele Piller the Administrator is going to email the current Certification. I introduced myself and explained the purpose of the visit.


LPA Benson and the Program Coordinator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to the common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medication file was also reviewed.

Common area was clean and in good repair. Craft area was clean, organized and in good repair. Kitchen was clean and in good repair. Medication is locked in a locked closet.

First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 05-30-23, the facility has been conducting drills every month.

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



Exit interview conducted and copy of report was provided to Mary McElwain the Program Coordinator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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