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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920059
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:45:15 PM

Document Has Been Signed on 10/04/2023 03:45 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:VILLA SIERRA LODGE - GREENBRAEFACILITY NUMBER:
345920059
ADMINISTRATOR:MAGPUSAO, MICHAELFACILITY TYPE:
735
ADDRESS:5933 SUTTER AVETELEPHONE:
(831) 869-2201
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 0DATE:
10/04/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Michael MagpusaoTIME COMPLETED:
03:45 PM
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On 10/4/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived announced at the facility to conduct a pre-licensing inspection utilizing the inspection tool. LPAs met with Administrator, Michael Magpusao, and explained the purpose of the visit.

During today's visit, LPAs and Administrator toured the interior and exterior of the facility. Areas toured included but not limited to: kitchen, dining room, staff room, four (4) private clients, (3) bathrooms, backyard, the staff quarrel and the common areas. LPAs observed carbon monoxide and fire alarms to be operating. LPAs observed the presence of locked cabinets for sharps and toxins, and a separate cabinet for medications. In areas toured, LPAs did not observe any concerns. LPAs observed clients room to be vacant, LPAs were informed once facility is licensed, all clients belongings will be transported to new facility.

Based on today's inspection, LPAs did not observe any health, safety, personal rights violations.

Comp III is waived as facility is doing a change of location.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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