<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920130
Report Date: 02/21/2024
Date Signed: 02/21/2024 11:19:43 AM

Document Has Been Signed on 02/21/2024 11:19 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:VILLA SIERRA LODGE - SPENLOWFACILITY NUMBER:
345920130
ADMINISTRATOR:MAGPUSAO, LUALHATIFACILITY TYPE:
735
ADDRESS:9051 WINDING OAK DRIVETELEPHONE:
(831) 869-2201
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 4CENSUS: 0DATE:
02/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Michael Magpusao, Acting AdministratorTIME COMPLETED:
11:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Hood met with Acting Administrator, Michael Magpusao, to conduct a Pre- Licensing visit. This application is a change of address. The previous license is named VILLA SIERRA LODGE - SPENLOW Facility #: 342700523. The facility has a fire clearance for four (4) ambulatory residents. Administrator Lualhati Magpusao has an active certificate (#6022281735 with expiration date 12/18/2024).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 119.2 degrees F. LPA observed facility has the ability to prepare and store food, to lock away cleaning products and other toxins, and lock medications to make inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational.

Component III was waived. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1