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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
515000503
Report Date:
05/15/2024
Date Signed:
05/15/2024 03:43:47 PM
Document Has Been Signed on
05/15/2024 03:43 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
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
PAUL AND LAURA HASE GUEST HOME
FACILITY NUMBER:
515000503
ADMINISTRATOR/
DIRECTOR:
HASE, LAURA
FACILITY TYPE:
735
ADDRESS:
2429 IVY STREET
TELEPHONE:
(530) 695-3905
CITY:
LIVE OAK
STATE:
CA
ZIP CODE:
95953
CAPACITY:
3
CENSUS:
3
DATE:
05/15/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:
Laura Hase
TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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LPA Hiratsuka conducted this unannounced annual visit.
This facility has a fire clearance for three ambulatory residents only. There are three private resident rooms. One resident room has a full private bathroom and there is one full common bathroom. There is a staff room and bathroom. There are a couple of common areas. There is an ample supply of perishable and nonperishable food.
Several topics were discussed.
The following shall be updated and submitted to Licensing by June 1 2024:
-LIC 500- facility personnel or staff schedule
-LIC 308- designation of administrative responsibility. (who is in charge when administrator is not present.)
No deficiencies cited during this visit.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/15/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/15/2024
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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