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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500312416
Report Date: 06/09/2021
Date Signed: 06/10/2021 07:22:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ORANGEBURG MANORFACILITY NUMBER:
500312416
ADMINISTRATOR:MARIE ARBIOSFACILITY TYPE:
740
ADDRESS:1248 NELSON AVENUETELEPHONE:
(209) 527-2222
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:0CENSUS: 0DATE:
06/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Joelle Costa, Resident Care CoordinatorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Bruce Jacobs conducted a facility visit to issue an amended licensing report. The report was initially issued on May 14th, 2021 detailing the findings from a complaint investigation. The report corrects the deficiency page (LIC 9099D) and the code for the deficiencies cited on May 14, 2021. LPA met with Resident Care Coordinator Joelle Costa and spoke to Executive Director Marie Arbios. Amended report issued.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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