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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507004929
Report Date:
10/31/2023
Date Signed:
11/20/2023 03:30:08 PM
Document Has Been Signed on
11/20/2023 03:30 PM
- It Cannot Be Edited
Document is an Amendment of
Original Document
on
11/20/2023 08:41 AM
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
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LPA Jensen arrived at facility unannounced to conduct a Plan of Correction visit related to deficiencies that were cited on 10/17/23 during the course of a quarterly Health and Safety visit. LPA Jensen met with care provider Eleanor and explained the purpose of today's visit. Marilou Oliver is the acting Administrator due to the Licensee/Administrator of record currently being out of the country.
On 10/17/23 the Licensee was cited for California Code of Regulations (CCR) 87208(a)(7)(A) - Plan of Operation. A plan of correction was received timely.
The Licensee submitted a sketch and attestation that the usage of each room is accurately depicted by the sketch and corresponds to the original fire clearance granted.
This report amends a report form 10/31/23 wherein a civil penalty was erroneously issued for failure to correct a deficiency.
An exit interview was conducted. A copy of this report was provided.
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Maja Jensen
TELEPHONE:
(916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE:
10/31/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/31/2023
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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