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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920066
Report Date: 05/20/2024
Date Signed: 05/20/2024 11:32:05 AM

Document Has Been Signed on 05/20/2024 11:32 AM - 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:VAN MOORE VILLAFACILITY NUMBER:
345920066
ADMINISTRATOR/
DIRECTOR:		NICULAI, SEFORAFACILITY TYPE:
740
ADDRESS:8924 VAN MOORE LANETELEPHONE:
(916) 218-8355
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 5DATE:
05/20/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Administrator, Sefora NiculaiTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 05/20/24, Licensing Program Analyst Talwinder Bains arrived to conduct an unannounced Post Licensing inspection. LPA met with Administrator, Sefora Niculai and explained the purpose of today's visit.

LPA reviewed 2 residents and 2 staff files. All residents files contained the required paperwork. Staff file contained the required paperwork and training. Facility is current on fire drills.

LPA toured the facility with Administrator. The following areas were inspected: backyard, resident rooms, resident bathrooms, kitchen, and common area. In the areas toured, there were no health or safety violations observed.

No deficiencies cited per Title 22 Regulations. An exit interview conducted. A copy of this report was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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