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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700377
Report Date:
07/16/2024
Date Signed:
07/16/2024 03:37:48 PM
Document Has Been Signed on
07/16/2024 03:37 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/
DIRECTOR:
CAMPOS, RENILYN
FACILITY TYPE:
740
ADDRESS:
3017 SUBARU CT
TELEPHONE:
(916) 701-5965
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95826
CAPACITY:
6
CENSUS:
5
DATE:
07/16/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:
Renilyn Campos
TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Vincent Moleski and ombudsman Ron Carrera arrived unannounced to conduct a case management visit. LPA Moleski and Carrera met with facility administrator Renilyn Campos and explained the purpose of the visit.
LPAs Moleski and Carrera interviewed a resident (R1) and reviewed facility records.
No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Campos.
SUPERVISORS NAME
:
Stephen Richardson
LICENSING EVALUATOR NAME
:
Vincent Moleski
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/16/2024
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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