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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
347004571
Report Date:
01/02/2024
Date Signed:
01/02/2024 03:48:03 PM
Document Has Been Signed on
01/02/2024 03:48 PM
- 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:
LADIORAY HOME INC.
FACILITY NUMBER:
347004571
ADMINISTRATOR:
MINA, LUZ M.
FACILITY TYPE:
735
ADDRESS:
4510 CAREYBACK AVENUE
TELEPHONE:
(916) 428-0392
CITY:
ELK GROVE
STATE:
CA
ZIP CODE:
95758
CAPACITY:
4
CENSUS:
4
DATE:
01/02/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:30 PM
MET WITH:
Luz Mina
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Luz Mina and explained the purpose of the visit.
LPA Moleski inspected resident bedrooms and discussed capacity limitations with Mina.
No deficiencies were cited during this visit and a copy of this report was left with Mina.
SUPERVISORS NAME
:
Stephen Richardson
LICENSING EVALUATOR NAME
:
Vincent Moleski
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/02/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/02/2024
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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