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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342701212
Report Date:
06/12/2024
Date Signed:
06/12/2024 10:55:42 AM
Document Has Been Signed on
06/12/2024 10:55 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
CARLTON SENIOR LIVING SACRAMENTO ATRIUM
FACILITY NUMBER:
342701212
ADMINISTRATOR/
DIRECTOR:
KASIE WIMMER
FACILITY TYPE:
740
ADDRESS:
1071 FULTON AVENUE
TELEPHONE:
(916) 971-4800
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95825
CAPACITY:
99
CENSUS:
53
DATE:
06/12/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:
KASIE WIMMER
TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 6/12/24 at 11:00am LPA Kevin Gould Conducted a POC clearance.
LPA confirmed POC documentation for in service training.
POC letter generated.
SUPERVISORS NAME
:
Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME
:
Kevin Gould
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/12/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2024
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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