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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700952
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:45:30 PM


Document Has Been Signed on 02/07/2023 02:45 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:PADUA ASSISTED LIVING 3FACILITY NUMBER:
342700952
ADMINISTRATOR:PADUA, NICHOLASFACILITY TYPE:
740
ADDRESS:9653 GLACIER CREEK WAYTELEPHONE:
(916) 218-8556
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 0DATE:
02/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Angelita DayoanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA called Licensee Angelita to inform that LPA was outside the facility to conduct a closure visit.

LPA did not observe any residents in care. LPA observe garbage cans in the front of street and no cars in front of the facility. According to the licensee, they do not have access into the home.

LPA requested the copy of the license be sent to the regional office via certified mail by COB 02/10/2023. Upon receipt of the license, LPA will close out the facility in system.

Licensee to complete exit survey: https://www.surveymonkey.com/r/facilityclosure

A copy of the closure excel was obtained. An exit interview was held with licensee, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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