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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700151
Report Date: 04/14/2023
Date Signed: 04/14/2023 03:33:41 PM


Document Has Been Signed on 04/14/2023 03:33 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ORANGE GROVE SENIOR LIVINGFACILITY NUMBER:
342700151
ADMINISTRATOR:VENEGAS, MARICAR MERCADOFACILITY TYPE:
740
ADDRESS:228 GRACE AVENUETELEPHONE:
(916) 993-9099
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 6DATE:
04/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Theresa Autencio TIME COMPLETED:
03:45 PM
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On April 14, 2023 At :30 PM, Licensing Program Analysts (LPA) Avelina Martinez and LPA Pang Lee arrived unannounced to deliver an Order of Exclusion for a staff member. LPAs Martinez and Lee met with Theresa Autencio and explained the purpose of today's visit.

LPAs Martinez and Lee were informed by Theresa Autencio, staff member named in the Order of Exclusion, Maricar Venegas no longer works at the facility. LPA Martinez also conducted a phone call with Christine Torres during today's visit. Christine Torres reported Maricar Venegas does not live at the facility, and does not visit the facility.

LPAs Martinez and Lee provided the Theresa Autencio with a copy of the Order and explained that Maricar Venegas is not allowed in the facility effective immediately.

Exit interview was held, and a copy of this report and Immediate Exclusion letter were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
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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