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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002630
Report Date: 04/21/2023
Date Signed: 04/21/2023 11:11:27 AM

Document Has Been Signed on 04/21/2023 11:11 AM - 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:NEW VISION SERVICES HOUSE 3FACILITY NUMBER:
455002630
ADMINISTRATOR:WILLIAMS, KENNETHFACILITY TYPE:
735
ADDRESS:3369 JOSH DRIVETELEPHONE:
(530) 364-2260
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY: 4CENSUS: 4DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Amber Watkins and Troy WatkinsTIME COMPLETED:
11:20 AM
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Kerry Hiratsuka and Sarah Benson Licensing Program Analyst (LPA) arrived unannounced for yearly annual review.

This facility has four private rooms. The main entrance opens to the main common, dining, and kitchen area. To the right of the main entrance is one private resident room. Just past that on the right leads to three private resident rooms, locked cabinet for files and medications, laundry area, and a second common area. The largest resident room has a full private bathroom and a sliding door leading to the backyard. The backyard has a locked shed.

During this visit the clients were at day program. The (LPA's) walked the entire house and outside area.

One staff and one resident file were reviewed.

Multiple topics were discussed.

No deficiencies cited.



SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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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