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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005521
Report Date: 10/20/2021
Date Signed: 10/20/2021 02:52:57 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:CARE GROUP AT HEATHMAN WAY, THEFACILITY NUMBER:
347005521
ADMINISTRATOR:JENNIFER LABIOSFACILITY TYPE:
740
ADDRESS:9473 HEATHMAN WAYTELEPHONE:
(916) 667-9414
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Nina MenezTIME COMPLETED:
03:00 PM
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On 10/20/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced case management visit regarding an individual who does not have clearance to work or enter this facility. At approximately 2:30 PM, LPA met with staff member, Nina Menez at the entrance of the facility. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

Facility staff called the Administrator, Monalisa Silapan, then LPA explained the purpose of the visit. The Administrator stated that they had initially applied for an exemption request for the individual in question, however, the facility never employed the individual in question. The Administrator states this individual never worked in the facility.

Exit interview conducted with staff member Nina Menez. A copy of this report will be emailed to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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