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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700877
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:08:17 PM


Document Has Been Signed on 11/15/2022 04:08 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ROBERT CREEK VILLA IFACILITY NUMBER:
342700877
ADMINISTRATOR:SBINGU, ADINAFACILITY TYPE:
740
ADDRESS:8135 ROBERT CREEK VILLA COURTTELEPHONE:
(916) 745-4230
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
11/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Adina Sbingu, Administrator TIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Calzada conducted an unannounced case management visit on 11/15/2022. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPA met with Maria Radu, caregiver, and stated the purpose of visit. LPA spoke to Adina, Administrator, by phone, who indicated she would be at the facility at approximately 3:55 pm.

Facility understands this is an Immediate Exclusion effective 11/10/2022 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Administrator stated that S1 never worked at this facility location and only worked at a related location in 2020. Administrator stated S1 had fingerprints completed for this location under the prior ownership as back-up staffing only, but he never worked at this location under the prior ownership either.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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