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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700151
Report Date: 04/19/2023
Date Signed: 04/19/2023 03:46:17 PM


Document Has Been Signed on 04/19/2023 03:46 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:
04/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Christine TorresTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Christine Torres and explained the purpose of the visit.

The purpose of the visit today, is in response to a change of Administrator and a corporation change- LIC 200 application follow up. LPA Martinez informed Christine Torres an LIC 200 application will need to be submitted to the Centralized Application Bureau (CAB), and LPA Martinez provided CAB's website and telephone number information.

https://www.cdss.ca.gov/inforesources/community-care/ascp-centralized-application-units
https://www.cdss.ca.gov/cdssweb/entres/forms/English/LIC200.pdf
CAB Phone number: (833) 827-6084

Christine reported she is working on submitting the LIC 200 application to CAB. In addition, the following Administrator documentation will need to be submitted to CCLD:
  • LIC 200 from licensee requesting administrator Change
  • Board Resolution for new administrator if corporation
  • LIC 308 Designation of Facility Responsibility
  • LIC 501 Personal Record
  • LIC 503 Health Screening Report
  • LIC 500 Personnel Report
  • Administrator Certificate

An exit interview was conducted, and a copy of this report was provided to Christine.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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