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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700493
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:40:12 PM

Document Has Been Signed on 03/20/2024 12:40 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:GREENBACK MANORFACILITY NUMBER:
502700493
ADMINISTRATOR:ABELLA, NICETASFACILITY TYPE:
735
ADDRESS:1604 CARLISLE AVETELEPHONE:
(209) 567-2080
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
03/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Nicetas AbelaTIME COMPLETED:
12:50 PM
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On 3/20/24 LPA Jensen arrived unannounced to conduct a case management for staffing. LPA Jensen met with Licensee Nicetas Abelas and explained the purpose of today's visit.

LPA Jensen requested an LIC 500, staff schedule and payroll records. The Licensee advised the LIC 500 and payroll records are off site and requested an opportunity to go and get the documentation. The Licensee also advised that the March 2024 staff schedule has not been printed as of yet due to the facility printer being in need of service. The Licensee provided the February 2024 schedule and retrieved the personnel records as requested.

LPA Jensen reviewed the staff schedule for February of 2024. There are 3 staff members. The schedule reflects that staff 3 (S3) works 7am until 10am and 3pm through 5pm on Monday through Thursday and 9pm Saturday through 1am on Sunday. All remaining shifts are covered by Staff 1 (S1) and Staff 2 (S2).

LPA Jensen interviewed the Licensee, she stated the facility has 2 staff on duty while clients are present and only on call staff when clients are not present. LPA Jensen also interviewed S2 during the course of this visit.
The California Minimum Wage Notice was observed to be posted. The staff room was observed to be used exclusively as a staff room. The food supply was observed to be sufficient.

Technical assistance is being provided in the areas of Inspection Authority of the Licensing Agency and Administrator Qualifications and Duties.

An exit interview was conducted and a copy of this report
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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