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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700990
Report Date: 02/22/2021
Date Signed: 02/22/2021 04:50:52 PM

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:VENEMAN CARE HOMEFACILITY NUMBER:
502700990
ADMINISTRATOR:RAMIT, LOLITAFACILITY TYPE:
740
ADDRESS:3605 NORTHAMPTON LANETELEPHONE:
(209) 623-7844
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 0DATE:
02/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:RAMIRO, LEILANITIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez contacted the facility via telephone to conduct a change of address pre-licensing visit on 02/22/2021 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the virtual visit, and the elements of the change of address pre-licensing visit with Leilani Ramiro.

LPA Martinez inspected the interior and exterior of the facility via virtual visit. The facility was observed to be in substantial compliance.

Resident's room were furnished, and sanitary. The kitchen was furnished, and the water temperature was 113 degrees. The laundry room has locked cabinets for cleaning supplies. The living room is furnished and has space for activities. Smoke/Carbon detectors are up today. The facility has a pool, which is enclosed. There is a locked fence around the pool. The facility has an exterior emergency exit gate. All facility files will be transferred to the new facility. The licensee will keep all current facility files and medication procedures in place.

The applicant has passed the change of address pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

An exit interview was conducted with Applicant Leilani Ramiro via virtual visit, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021
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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