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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 06/07/2023
Date Signed: 06/07/2023 04:08:26 PM


Document Has Been Signed on 06/07/2023 04:08 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:ARBOR PLACEFACILITY NUMBER:
397004353
ADMINISTRATOR:BELINDA GUZMANFACILITY TYPE:
740
ADDRESS:17 LOUIE AVETELEPHONE:
(209) 369-8282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:76CENSUS: 46DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Belinda Guzman, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Belinda Guzman. The administrator currently holds a certificate (#6012558740) that expires on 01/22/2024.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 48 total bedrooms of which 46 bedrooms are occupied by the residents and no bedroom is occupied by staff. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 75 degrees Fahrenheit. The hot water temperature in the residents’ bathroom was measured at 115 degrees Fahrenheit. Night lights are maintained in hallways and passages to nonprivate bathrooms. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

No deficiencies were observed during this inspection.
Exit interview conducted. Appeal Rights and a copy of this report provided.
The following forms to be updated and submitted to CCL by 06/13/2023

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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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