<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 02/13/2023
Date Signed: 02/14/2023 09:57:51 AM


Document Has Been Signed on 02/14/2023 09:57 AM - 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 AC/SC, 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: 172DATE:
02/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kaylie McCortney and Christina HowardTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Unannounced case management visit made out to this facility on 02/13/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who were met by the Care Operations Manager, Kaylie McCortney, and the Assisted Living Manager, Christina Howard, who were both briefly interviewed.
Current census was 172 residents spread out over the licensed individual buildings on this property address.
The purpose of this visit was to follow up on an Unusual Incident Report that was recently submitted involving R1 and R2.
Due to the nature of the incident and the parties involved, LPAs Charlie Yang and Kimberly Viarella were present today to gather information and better understand the details surrounding the most recent incident, involving R1 and R2, and the course of action that this facility was taking to assist their residents.

Based on information gathered during this case management visit, it was determined that this facility acted in accordance with the rules and regulations set forth in Title 22.

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

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1