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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700876
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:19:03 PM


Document Has Been Signed on 01/04/2023 12:19 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:A LOVING PLACEFACILITY NUMBER:
502700876
ADMINISTRATOR:MARTHA ARREGUINFACILITY TYPE:
740
ADDRESS:2800 CATALA WAYTELEPHONE:
(209) 360-2198
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 5DATE:
01/04/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Martha ArreguinTIME COMPLETED:
12:15 PM
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On 1/4/22 at approximately 11:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a case management for health and safety checks. LPA Jensen met with Administrator Martha Arreguin and explained the purpose of today's visit.

There is currently a Winter Storm warning in effect. The facility has power and heat at this time. There are currently 5 residents. At this time there is sufficient staffing. On January 1, 2023 the census changed from 6 to 5. LPA Jensen observed a two day supply of perishable food and a 7 day supply of non-perishable food.

LPA Jensen observed 5 of 5 residents that appeared to have all their needs met. LPA Jensen conducted an interview with Administrator Martha Arreguin and documented the conversation on an LIC 812. Licensee will submit proof of refund to maja.jensen@dss.ca.gov for resident 6 (R6) to community care licensing no later than 1/15/23.

No citations were issued as a result of this visit.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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