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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700787
Report Date: 04/27/2023
Date Signed: 05/02/2023 04:45:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/02/2023 04:45 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LIBBIE CARE HOMEFACILITY NUMBER:
392700787
ADMINISTRATOR:RAM, AVINESHFACILITY TYPE:
735
ADDRESS:558 E EDISON STTELEPHONE:
(209) 824-5993
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 5CENSUS: DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:No One PresentTIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 04/27/2023 by Licensing Program Analyst (LPA) Charlie Yang.
Several attempts were made to ring the doorbell and gain access into this facility. After several minutes without any response, this LPA retreated back to his car.
A phone call was made to the facility contact number, (209) 824-5993, and this LPA was unable to make contact with the facility designated Administrator, Avinesh Ram, at this time.
The phone would automatically disconnect after a few rings. This LPA verified the number several times and dialed it several times and achieved the same result.
Another phone call attempt was made to the cell phone number, (925) 895-0756, listed on the facility profile.
This LPA was unable to reach the facility Licensee, Rene Tang, on the cell phone but was able to leave a brief voicemail detailing the nature of the call and left his contact information at this time.
A return call was made by Rene Tang to this LPA after a bit of time (15 mins) had passed.
A brief interview was conducted with the facility Licensee at this time.

Another follow up visit will have to be made in order to gain access to this facility, review facility personnel/resident files, and interview residents and staff alike.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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