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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700821
Report Date:
05/22/2024
Date Signed:
05/22/2024 03:13:28 PM
Document Has Been Signed on
05/22/2024 03:13 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:
BLUEBERRY HILL SENIOR LIVING, INC.
FACILITY NUMBER:
342700821
ADMINISTRATOR:
HAMRIC, KEITH
FACILITY TYPE:
740
ADDRESS:
3827 OLIVE LANE
TELEPHONE:
(916) 900-8399
CITY:
CARMICHAEL
STATE:
CA
ZIP CODE:
95608
CAPACITY:
6
CENSUS:
5
DATE:
05/22/2024
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
01:35 PM
MET WITH:
Dana Ford and Keith Hamric
TIME COMPLETED:
01:46 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Caregiver who then contacted Administrator who then arrived to the facility shortly.
LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system.
There are no citations issued on this report.
Exit interview. Copy of report provided.
SUPERVISOR'S NAME:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Cassie Yang
TELEPHONE:
(916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE:
05/22/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/22/2024
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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