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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701303
Report Date: 09/07/2023
Date Signed: 09/07/2023 10:24:32 AM

Document Has Been Signed on 09/07/2023 10:24 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ND CARE HOMEFACILITY NUMBER:
342701303
ADMINISTRATOR:MACALIBO, NOVETTE DFACILITY TYPE:
735
ADDRESS:2112 MCGREGOR DRIVETELEPHONE:
(719) 200-9105
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 0DATE:
09/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Novette MacaliboTIME COMPLETED:
11:00 AM
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On 9/7/23 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at ND Care Home for the purpose of conducting a required Component III Orientation. LPA met with Licensee, Novette Macalibo and together conducted the orientation.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, and Health Related Services and Conditions.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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