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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920059
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:32:12 PM

Document Has Been Signed on 09/10/2024 04:32 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: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: DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:28 PM
MET WITH:Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced on 9/10/2024 to conduct a required 1 year annual inspection. LPA met with Sotero Toca and explained the purpose of the visit.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. Areas toured included but not limited to: clients bedrooms, bathroom, kitchen, laundry room and the common areas. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms observed to be in sanitary condition, properly maintained.

LPA checked the kitchen area for the ability to prepare and store food, facility has (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPAs observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPAs observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care.

LPA conducted interviews with two clients, two other clients were observed to be resting in their room. CARE tool completed with DSP and facility was found to be in compliance. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22.

Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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