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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700041
Report Date: 04/12/2021
Date Signed: 04/14/2021 08:21:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SPIVA ACRESFACILITY NUMBER:
342700041
ADMINISTRATOR:AMIN, BHAVESHFACILITY TYPE:
740
ADDRESS:10396 SPIVA ROADTELEPHONE:
(925) 399-1180
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:12CENSUS: 0DATE:
04/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Bhavesh AminTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Tung Truong contacted Administrator, Bhavesh Amin, via google duo tele-visit to conduct a virtual inspection proceeding the closure of the facility on 4/12/2021. A Notice of Facility Closure was received by the Regional Office with a facility closure date of 5/18/2021. The visit was conducted via telephone due to COVID-19 and precautionary measures.

LPA toured the facility with the administrator. LPA observed that there were no residents at the facility.

LPA advised Administrator to mail the original License to the Regional Office and that the facility will be closed in the system as of 04/12/2021. A copy of this report has been emailed to the Administrator and the Administrator was advised that a signed copy of this report shall be submitted to CCLD within 10 days of receipt of this report.

Link to survey for Facility Closure provided to Bhavesh Amin.

www.surveymonkey.com/r/facilityclosure


Exit interview conducted and a copy of this report was emailed to the administrator.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
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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