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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700947
Report Date:
07/24/2024
Date Signed:
07/24/2024 10:57:17 AM
Document Has Been Signed on
07/24/2024 10:57 AM
- 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:
BELHAVEN ESTATE
FACILITY NUMBER:
342700947
ADMINISTRATOR:
WILSON, JENNIFER
FACILITY TYPE:
740
ADDRESS:
9048 ELM AVE
TELEPHONE:
(831) 801-4626
CITY:
ORANGEVALE
STATE:
CA
ZIP CODE:
95662
CAPACITY:
6
CENSUS:
6
DATE:
07/24/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
House Manager- Kylie Moss
TIME COMPLETED:
11:00 AM
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On 07/24/24
Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a case management visit. LPM and LPAs met with Kylie Moss.
LPAs conducted a walk through of the facility. LPAs observed three (3) residents in the living room watching television and two (2) doing exercises in another. LPAs did not observe health and safely concerns in the areas that were toured.
No deficiencies were observed during todays visit.
Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Cheyenne Ratajczak
TELEPHONE:
(916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2024
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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