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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700805
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:47:55 PM


Document Has Been Signed on 08/31/2023 01:47 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:NORTHERNCARE FACILITYFACILITY NUMBER:
342700805
ADMINISTRATOR:WOODWARD, ROSE BALUROFACILITY TYPE:
740
ADDRESS:5016 WATERBURY WAYTELEPHONE:
(530) 762-8199
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
08/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rose Baluro Woodward, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Rose Baluro Woodward, to follow-up on plan of corrections made to the facility on 6/30/2023 to be completed on 7/1/2023 and 7/31/2023

During today's visit, LPA took the temperature of the water and found temperature to be 107 degrees F. LPA observed that facility had LIC 602A for resident (R1) on file.

LPA cleared deficiencies as of today's date.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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