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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700588
Report Date: 10/09/2024
Date Signed: 10/09/2024 03:48:07 PM


Document Has Been Signed on 10/09/2024 03:48 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SIGNATURE LIVING ON WINDING WAYFACILITY NUMBER:
342700588
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6258 WINDING WAYTELEPHONE:
(916) 812-0944
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Placida Devera, Assistant AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility unannounced on 10/09/2024 to conduct a case management visit in relation to a separate inspection.

During visit, LPAs followed-up regarding concerns with a resident's ambulatory status. Technical assistance was provided by LPAs.

As a result of today's inspection, no deficiencies are being cited pursuant to California Code of Regulations, Title 22.

Exit interview was conducted with Assistant Administrator. A copy of this report was provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassandra MikkelsonTELEPHONE: 916-709-6830
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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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