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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700853
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:45:41 PM

Document Has Been Signed on 08/20/2021 03:45 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:ASTORIA VISTAFACILITY NUMBER:
342700853
ADMINISTRATOR:QUIDILIG, KARENFACILITY TYPE:
740
ADDRESS:8616 BANFF VISTA DRIVETELEPHONE:
(916) 714-4897
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Monalisa LegaspiTIME COMPLETED:
04:05 PM
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On 8/20/21 at 3:23pm, Licensing Program Analyst (LPA) Michael Bilger conducted a case management visit at the facility and met with Monalisa Legaspi. The purpose of the visit was to verify that one excluded employee (S-1) is not working at the facility and has been removed from the facility. Per Monalisa Legaspi, the employee has not been working at the facility since 8/4/2019 and has been removed from the facility. A copy of the current personnel report was obtained and verified that the employee is no longer working at the care home.

An exit interview was conducted with Monalisa Legaspi and a copy of this report was left with Monalisa.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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