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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920059
Report Date: 05/02/2024
Date Signed: 05/02/2024 01:09:54 PM

Document Has Been Signed on 05/02/2024 01:09 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/
DIRECTOR:		MAGPUSAO, MICHAELFACILITY TYPE:
735
ADDRESS:5933 SUTTER AVETELEPHONE:
(831) 869-2201
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 4DATE:
05/02/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sotero Toca and Michael MagpusaoTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 5/2/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post-licensing inspection utilizing the care tool. LPA met with caregiver, who contacted Administrator who arrived to the facility after facility tour was conducted. Note: Time of visit was extended due to a break during the visit.

During today's inspection, LPA and Caregiver conducted a tour of the interior of the facility. LPA observed the presence of two clients in care. LPA was informed the other two clients are at adult day program. LPA observed medications to be locked. LPA informed caregiver to ensure key to locked cabinets are stored in an area inaccessible to clients and/or in caregiver's possession at all times. LPA did not observed sharps to be in the kitchen, LPA was informed sharps were kept in staff room. LPA observed chemicals and other toxins to be locked in the cabinet next to the laundry room. LPA observed laundry room to be free of detergents. LPA observed fire extinguisher to be serviced on 6/14/23. LPA observed documentation of fire drill to be conducted on 1/21/24; 2/12/24; 3/27/24; and 4/21/24. LPA observed the facility to have ample supply of nonperishable and perishable foods. LPA and Administrator discussed the possibility of change of facility use from adult residential facility to residential care facility for the elderly.

File review conducted for C1, C2, C3 and C4. LPA completed the post-licensing care tool and found facility to be in substantial compliance.

At this time, Administrator stated no concerns at the facility. No deficiencies cited.

Exit interview and a copy of report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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