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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515000503
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:20:30 PM

Document Has Been Signed on 05/16/2023 04:20 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:PAUL AND LAURA HASE GUEST HOMEFACILITY NUMBER:
515000503
ADMINISTRATOR:HASE, LAURAFACILITY TYPE:
735
ADDRESS:2429 IVY STREETTELEPHONE:
(530) 695-3905
CITY:LIVE OAKSTATE: CAZIP CODE:
95953
CAPACITY: 3CENSUS: 3DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Laura Hase, Paul Hase. TIME COMPLETED:
04:30 PM
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On 5/16/2023 LPA Tryon visited the facility to do an annual visit. LPA met with licensees Paul and Laura Hase.
LPA toured the facility including common areas, kitchen, dining, bedrooms, bathrooms, hallways, sunroom, yard, laundry.
The facility is nicely furnished and decorated, is very clean and in good condition. Bedrooms are appropriately furnished as per regulation. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Food is appropriately stored.
Smoke detectors and carbon monoxide detector installed. Fire extinguishers present and charged.

LPA reviewed the CARE Tool with licensee.

At this time, it appears that the facility is in substantial compliance with the regulations. No deficiencies were cited at this time. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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