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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002721
Report Date: 08/10/2020
Date Signed: 08/10/2020 01:05:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ADINA HOME CAREFACILITY NUMBER:
347002721
ADMINISTRATOR:LUP, ILEANAFACILITY TYPE:
740
ADDRESS:260 BAURER CIRCLETELEPHONE:
(916) 817-2471
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 0DATE:
08/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Nick Lup (Caregiver)TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Konnor Leitzell contacted the facility via telephone to commence a case management for incident report received. Due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call with caregiver, Nick Lup and Admin Ileana Lup.

The caregiver and admin were advised that at this time the case management may require further possible follow-up telephone calls or visits are necessary.

An exit interview was conducted with Administrator Lup via telephone and a copy of this report along was provided to Administrator Lup via email and an electronic email read receipt confirms receiving these documents.

Administrator stated they will sign and return a copy of this report for our records, as well as saving once copy for their records.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020
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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