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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003709
Report Date: 06/13/2024
Date Signed: 06/14/2024 08:47:49 AM


Document Has Been Signed on 06/14/2024 08:47 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CHANCELLOR MANORFACILITY NUMBER:
507003709
ADMINISTRATOR:CLARITA RAMISCALFACILITY TYPE:
740
ADDRESS:5707 CHANCELLOR WAYTELEPHONE:
(209) 858-8830
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY:6CENSUS: 5DATE:
06/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nicetas AbellaTIME COMPLETED:
12:30 PM
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Unannounced case management visit made out to this facility on 06/13/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregivers, Francisco Enriquez and Jessica Mamangon, who were briefly interviewed.
This LPA requested that they go ahead and contact the facility designated Administrator, Nicetas Abella, to inform her that CCL was present at this time.
Current census was 5 residents.
The facility designated Administrator, Nicetas Abella, arrived shortly thereafter to this facility while this LPA was conducting this visit.
A brief interview was conducted with the facility designated Administrator at this time.
The purpose of this visit was to follow up with the facility designated Administrator, Nicetas Abella, about the forfeiture of licensure for this facility and her pending application for this property location at this time.
It was learned that an application was accepted with the Central Applications Bureau (CAB) on 04/23/2024 with revisions pending at this time.
A fire clearance was granted for (6) non ambulatory residents on 05/09/2024 by the Stanislaus Consolidated Fire District.
The applicant, Nicetas Abella, was in the process of completing the Component II interview which was scheduled for 06/13/2024 at 1:00 pm at this time.
It was observed that the Applicant was progressing towards licensure and taking the necessary measures to achieve that at this time.

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

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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