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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004963
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:30:05 PM


Document Has Been Signed on 12/14/2023 12:30 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MILES MANORFACILITY NUMBER:
347004963
ADMINISTRATOR:MILES, RACHELFACILITY TYPE:
740
ADDRESS:4301 WATKINS DRIVETELEPHONE:
(916) 967-9049
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:15CENSUS: 15DATE:
12/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Kimberly Rosa, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Kimberly Rosa, to follow-up on plan of corrections made to the facility on 11/15/2023 to be completed on 11/16/2023 and 12/08/2023.

During today's visit, LPA took the temperature of the water and found temperature to be 120 degrees F. LPA observed holes in floors to be repaired, kitchen shelves to be repaired, locks on kitchen shelves to be operable, and smoke alarms to be attached to ceiling.

LPA cleared deficiencies during visit.

Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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