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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700526
Report Date: 07/11/2024
Date Signed: 07/11/2024 08:02:34 PM

Document Has Been Signed on 07/11/2024 08:02 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:MIH-3 CARE HOMEFACILITY NUMBER:
502700526
ADMINISTRATOR/
DIRECTOR:		RYAN, MICHAELFACILITY TYPE:
735
ADDRESS:5413 FARMERS LNTELEPHONE:
(209) 244-3898
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 4CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Administrator Cami AzevedoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst, (LPA) Jason Lund made an unannounced case management visit to this facility and met with Administrator Cami Azevedo and explained the reason for the visit. Census:4

The facility has sent CCL eight Valley Mountain Regional Center Special Incident Reports that Client (C1) went AWOL from the dates from 6/21/2024 through 7/4/2024. On 7/8/2024 the facility had a meeting with Valley Mountain Reginal Center, Conservator, Facility and C1. During the meeting all above agreed to change C1’s time to check in. The facility will continue to report any AWOL’s.


Exit interview and report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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