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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 09/06/2023
Date Signed: 09/12/2023 02:07:10 PM


Document Has Been Signed on 09/12/2023 02:07 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 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: DATE:
09/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rikki PerezchicaTIME COMPLETED:
03:30 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 09/06/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Rikki Perezchica who was briefly interviewed at this time.
Current census was 177 residents spread out over the licensed individual buildings on this property address.
The purpose of this visit was to follow up on a Decision and Order in regards to S1 who was deemed to be excluded from being present, employed, or have any contact with any licensed facility by this Department.
It was learned that S1 was terminated from employment on 10/17/2019 and has not been present in this facility since that date.
This LPA was also present to discuss the most recent reports of fiduciary abuse involving R1 and the parties involved at this time. No pending action was taken at the time of this visit. This facility was monitoring for any unusual events and would report all incidents into CCL.

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: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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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