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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700139
Report Date:
03/11/2024
Date Signed:
03/11/2024 03:32:39 PM
Document Has Been Signed on
03/11/2024 03:32 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
BASTONA MANOR
FACILITY NUMBER:
342700139
ADMINISTRATOR:
VILLANUEVA, ROWENA
FACILITY TYPE:
735
ADDRESS:
1808 BASTONA DRIVE
TELEPHONE:
(916) 667-8721
CITY:
ELK GROVE
STATE:
CA
ZIP CODE:
95758
CAPACITY:
6
CENSUS:
5
DATE:
03/11/2024
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
03:15 PM
MET WITH:
Marilyn Schumacher
TIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a collateral visit. LPA Moleski spoke with facility administrator Rowena Villanueva over the phone and explained the purpose of the visit. Villanueva said staff member Marilyn Schumacher could sign this report in her absence.
LPA Moleski interviewed a resident.
No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Schumacher.
SUPERVISORS NAME
:
Stephen Richardson
LICENSING EVALUATOR NAME
:
Vincent Moleski
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/11/2024
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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