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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:01:36 PM


Document Has Been Signed on 11/09/2023 03:01 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 106DATE:
11/09/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shafhia HargrowTIME COMPLETED:
03:15 PM
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On 11/09/23 Licensing Program Analysts (LPAs) Kimberly Viarella and Albert Johnson made an unannounced Case Management visit to the residence of Shafhia Hargrow to serve her an Immediate Exclusion letter along with copies of the Declaration of Service, and Appeal Rights.

LPAs telephoned Shafhia Hargrow upon their arrival in order to gain entrance to her apartment complex. LPA Albert Johnson left a voicemail letting Ms. Hargrow know that there were representatives from the Department of Social Services on the premises and that they would like to speak with her briefly. Shafhia Hargow did not respond. LPAs were provided access to the complex by a resident of the building and they went directly to Ms Hargrow's apartment. LPAs knocked but no one answered the door. LPA Kimberly Viarella left a business card attached to the clip that was already present.

LPA Viarella sent the Immediate Exclusion letter along with copies of the Declaration of Service, and Appeal Rights to Shafhia Hargrow by certified mail.


Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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