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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 01/19/2024
Date Signed: 01/23/2024 09:12:06 AM


Document Has Been Signed on 01/23/2024 09:12 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/23/2024 08:59 AM

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

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On 1/19/2024, at 4:23 pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit and return a resident file. LPA met with Maria Estrada and explained the purpose of the visit. Today’s visit there were 1 resident in care with 2 staff on duty.

On 1/11/24, this facility was visited by another LPA and requested to remove resident1 (R1) file for the purpose of copying relevant documents at the Regional Office. Licensee was made aware of this request.

During this visit, LPA Villanueva returned R1’s file and was received by Maria Estrada. Also, Maria provided LPA copies of LIC602 of 9 residents as requested by the Department.

Per California Code of Regulations, Title 22, no citations were issued during this visit. An exit interview was held with Maria and a copy of this report was provided.

Note: This report was amended due to incorrect date at the second paragraph and incorrect number of resident's LIC602s provide.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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