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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003604
Report Date: 03/10/2021
Date Signed: 03/10/2021 01:30:12 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:FELICIA'S RESIDENTIAL CARE FACILITY FOR ELDERLYFACILITY NUMBER:
347003604
ADMINISTRATOR:RAMIREZ, FELICIA R.FACILITY TYPE:
740
ADDRESS:9495 DEANNA AVENUETELEPHONE:
(916) 987-1843
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 0DATE:
03/10/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Felicia and Vanessa RamirezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Wolter conducted an announced video visit to conduct a final walk through of the facility on 03/10/2021 due to COVID-19 and precautionary measures, LPA met with licensee, Felicia Ramirez, and staff, Vanessa Ramirez during today's visit.

LPA and Vanessa toured the facility together virtually, LPA observed facility to be free of residents and rooms appeared free of resident belongings. The last resident moved out 03/09/2021.

Licensee sent LPA a roster of where residents relocated to on 03/09/2021.

LPA explained to licensee that should she wish to operate a facility again in the future that a new fire clearance and application would need to be completed, licensee stated she understood.

Licensee to return facility license to Regional Office by either USPS or drop off.

Facility is closed as of 03/10/2021.

Exit interview conducted and a copy of this report was sent to licensee virtually, a signed copy to be returned to Community Care Licensing either by fax, email, or USPS. A signed copy should also be retained for records.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
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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