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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700377
Report Date:
11/16/2023
Date Signed:
11/16/2023 04:07:28 PM
Document Has Been Signed on
11/16/2023 04:07 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:
LIBERTAD MANOR
FACILITY NUMBER:
342700377
ADMINISTRATOR:
CAMPOS, RENILYN
FACILITY TYPE:
740
ADDRESS:
3017 SUBARU CT
TELEPHONE:
(916) 701-5965
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95826
CAPACITY:
6
CENSUS:
6
DATE:
11/16/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:45 PM
MET WITH:
Renilyn Campos
TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with Renilyn Campos and explained the purpose of the visit.
LPA Moleski discussed reporting requirements with Campos.
An exit interview was held and a copy of this report was left with Campos.
SUPERVISOR'S NAME:
Stephen Richardson
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
11/16/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
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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