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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003867
Report Date: 03/26/2021
Date Signed: 04/08/2021 10:30:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ELDERLY LOVE CARE HOMEFACILITY NUMBER:
347003867
ADMINISTRATOR:LIBERATO, ELSIEFACILITY TYPE:
740
ADDRESS:5639 BRIDGECROSS DRIVETELEPHONE:
(916) 418-4085
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:6CENSUS: 0DATE:
03/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elsie Liberato, LicenseeTIME COMPLETED:
10:00 AM
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On March 26, 2021 at 9am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons, conducted a case management visit to this facility. The purpose of the visit is to conduct a closure walk through.

The Licensee submitted a closure plan and 30 day notices to CCL on June 2020. LPA observed 0 people in the house during today's walk through. LPAs determined no one currently resides in this house as a residents.

Licensee returned the original license in person to the regional office on 3/23/2021. LPA informed the Licensee that this facility is officially closed as of today, 3/26/2021 and will be closed out in the Department's system.

LPA informed the Licensee that as of today, this property is no longer licensed. Should the Licensee wish to re-open this facility, a new application would be required.

Exit Interview and copy of report provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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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