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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002830
Report Date: 05/17/2023
Date Signed: 05/17/2023 01:16:07 PM

Document Has Been Signed on 05/17/2023 01:16 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:REM CALIFORNIA, LLC - SAN JUANFACILITY NUMBER:
345002830
ADMINISTRATOR:DOVE-MOSLEY, TAUKOSHIUAFACILITY TYPE:
735
ADDRESS:3831 SAN JUAN AVENUETELEPHONE:
(916) 550-0668
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 4DATE:
05/17/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Susana Magana, Regional DirectorTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angela Hood and Sabrina Calzada arrived unannounced to conduct a required annual.
LPAs met Susana Magana, Regional Director and explained purpose of inspection.

This report is being generated to document that an annual inspection was conducted on 5/17/2023, on a separate report, and to clear a post-licensing inspection from being due in the system.

There are no deficiencies being issued today on this report.

Exit interview. Copy of report left with Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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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