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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005251
Report Date: 10/22/2020
Date Signed: 10/22/2020 04:51:21 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:ATRIA CARMICHAEL OAKSFACILITY NUMBER:
347005251
ADMINISTRATOR:HAGEN, KIMBERLYFACILITY TYPE:
740
ADDRESS:8350 FAIR OAKS BLVDTELEPHONE:
(916) 944-2323
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:95CENSUS: 81DATE:
10/22/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Kimberly Hagen, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Bethany Huusfeldt conducted a case management visit to the facility on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. LPA met with Administrator, Kimberly Hagen and explained the purpose of today's visit. Staff, Kim Atkinson, is excluded as a result not related to this facility.

LPA Huusfeldt handed the Order to Licensee/Facility of Immediate Exclusion From Facility letter to Vicky Cross and explained that staff, Kim Atkinson, is not allowed back at the facility.

A copy of this report was provided to Administrator
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
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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