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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920017
Report Date: 05/14/2024
Date Signed: 05/14/2024 02:32:55 PM

Document Has Been Signed on 05/14/2024 02:32 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ILLINOIS HOME, LLCFACILITY NUMBER:
345920017
ADMINISTRATOR/
DIRECTOR:		SAMSON, DEXTER C.FACILITY TYPE:
737
ADDRESS:5035 ILLINOIS AVETELEPHONE:
(916) 206-9433
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 4CENSUS: 4DATE:
05/14/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Dexter C. Samson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Hood arrived at the care home today and met with the Administrator, Dexter Samson, to conduct an annual required and post licensing visit.

For more information on the post licensing visit, please see LIC 809 for Required - 1 Year dated 5/14/24.

No deficiencies cited for the post licensing visit.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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