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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001971
Report Date: 11/21/2024
Date Signed: 11/21/2024 10:18:46 AM

Document Has Been Signed on 11/21/2024 10:18 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:RICK AND NICOLE FORTES CARE HOMEFACILITY NUMBER:
347001971
ADMINISTRATOR/
DIRECTOR:		FORTES, NICOLEFACILITY TYPE:
735
ADDRESS:5545 VILLAGE WOOD DRIVETELEPHONE:
(916) 395-3225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 6DATE:
11/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Nicole FortesTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 11/21/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conduct a case management visit. LPA met with staff on duty (S1) and stated the purpose of the visit. All residents in care were out in the community during this visit.

The purpose of this case management visit is for LPA to deliver an amended report.

Exit interview was conducted with Nicole Fortes and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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