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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 09/14/2022
Date Signed: 09/20/2022 12:58:37 PM


Document Has Been Signed on 09/20/2022 12:58 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:SAMARITAN VILLAGEFACILITY NUMBER:
507002396
ADMINISTRATOR:RIKKI PEREZCHICAFACILITY TYPE:
740
ADDRESS:7700 FOX ROADTELEPHONE:
(209) 883-3000
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY:277CENSUS: 179DATE:
09/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Christina HowardTIME COMPLETED:
02:00 PM
NARRATIVE
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Unannounced case management visit conducted out at this facility on 09/14/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Assisted Living Manager (ALM) Christina Howard who was briefly interviewed.
The purpose of this visit was to follow up on Unusual Incident Reports (UIRs) that have been submitted into CCL by this facility for the following dates:
  • 04/13/2022

  • 08/30/2022

  • 07/22/2022

  • 06/28/2022


A discussion was held with the ALM in terms of follow up and any updates, if warranted, at this time.

There were no deficiencies observed or cited during today's case management visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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