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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300536
Report Date: 06/15/2023
Date Signed: 06/15/2023 08:18:40 PM


Document Has Been Signed on 06/15/2023 08:18 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/15/2023 08:16 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

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LPA Albert Johnson made an unannounced visit to the facility to verify correction of citations issued during the POC visit conducted on 06/05/2023 .

Citation 87405(a) Administrator- Qualifications and Duties:
(All Facilities shall have a qualified and currently certified administrator).

The facility has not identified an acting Administrator. The facility has not provided the required documentation and will be assessed civil penalties for failure to correct this citation.

LPA was made aware that some residents have been encouraged to leave the facility and have had visits from other facilities to assess them.

The remaining residents appear to be safe and there were staff working this evening.

Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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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