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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 04/03/2024
Date Signed: 07/30/2024 01:54:08 PM


Document Has Been Signed on 07/30/2024 01:54 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 57DATE:
04/03/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Belinda Guzman TIME COMPLETED:
10:15 AM
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A stipulation and waiver and order meeting was conducted today on April 03, 2024 via Microsoft Teams with the Sacramento South Regional Office at 9:00 AM. Present at today's meeting include the following: Licensing Program Manager Stephenie Doub, Licensing Program Manager Liza King, and Licensing Program Analyst Avelina Martinez: Facility Representatives: Ashley Dava, Rosalie Sullivan, Belinda Guzman; and Ombudsman Representative: Kathryn Thomas.

During today's virtual meeting, Community Care Licensing Department (CCLD) read the stipulation and waiver and order to facility representatives. In addition, facility representatives were informed the updated plan of operation shall be submitted to CCLD by April 21, 2024 by 5:00 PM.

An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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