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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:17:01 PM


Document Has Been Signed on 08/15/2023 01:17 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:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 3DATE:
08/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:CANDIDO, CECILIATIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit regarding deficiencies from complaint 27-AS-20230616122253. LPA was greeted by licensee and explained the reason for the visit.

Licensee was to complete a plan of correct that included providing a refund to R1 with in 3 days which was completed, additionally the license was to update all admissions agreements with required information for all residents and provide a copy to the department via the LPA by 7/24/2023 then 8/11/2023 this was not completed. updates can be emailed to LPA Lewis at Kesha.Lewis@dss.ca.gov. see 809D from 08/02/2023 and 9099D from 07/12/2023. Licensee was able to show LPA an email that was sent on 8/11/2023 containing the required documentation, the LPA'S email address was incorrect. Licensee forwarded the email to LPA on 8/11/23.

Exit interview copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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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