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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000825
Report Date: 04/28/2021
Date Signed: 04/28/2021 01:24:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GREEN BELT CARE HOMEFACILITY NUMBER:
347000825
ADMINISTRATOR:COPACIU, REGHINAFACILITY TYPE:
740
ADDRESS:9039 WINDING OAK DRIVETELEPHONE:
(916) 989-9255
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 0DATE:
04/28/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Reghina Copaciu, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Angela Hood contacted Licensee, Reghina Copaciu, via face-time tele-visit to conduct a virtual inspection proceeding the closure of the facility. A Notice of Facility Closure dated 2/15/21 was received by the Regional Office. The visit was conducted via telephone due to COVID-19 and precautionary measures.

LPA observed interior/exterior of the facility, including the yard, living room, dining room, kitchen, 2 bathrooms, and 4 bedrooms. LPA observed that there were no residents at the facility.

LPA received the original License and the facility will be closed in the system as of 4/28/2021. A copy of this report has been emailed to the Licensee and the Licensee was advised that a signed copy of this report shall be submitted to CCLD.

Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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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