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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700651
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:41:22 PM


Document Has Been Signed on 04/12/2022 03:41 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:PADUA ASSISTED LIVINGFACILITY NUMBER:
342700651
ADMINISTRATOR:PADUA, NICHOLASFACILITY TYPE:
740
ADDRESS:7019 MCGILL COURTTELEPHONE:
(916) 647-3483
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
04/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Angelita Dayoan, LicenseeTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced 4/12/22 at 3:30p to obtain a complete resident file for Community Care Licensing (CCL) review.

Angelita Dayoan, Licensee stated that on a previous visit (12/16/21) LPA Tirzah Hubbard arrived and retrieved the complete file for Resident #1 (R1). She stated there are no other documents in the facility for R1. Angelita stated she offered to make a copy for LPA but was told the file will be brought back to the facility. Angelita presented an email between her and LPA for that day regarding the facility visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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