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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001963
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:55:11 PM


Document Has Been Signed on 12/14/2023 12:55 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:WILLOW GLEN CARE CENTERFACILITY NUMBER:
515001963
ADMINISTRATOR:ANGIE KARISFACILITY TYPE:
740
ADDRESS:1547 PLUMAS COURTTELEPHONE:
(530) 751-9900
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:60CENSUS: 58DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Angie KarisTIME COMPLETED:
01:05 PM
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LPA Hiratsuka conducted this unannounced annual visit.

The main entrance of this building opens to a reception area that is shared by Rosewood Care Center 517003766 which is licensed by Community Care Licensing Division. The entrance to the facility itself is to the right of the main reception area. This facility has a layout of the main common area that has the dining and there are two wings. There is a medication area in the middle of the wings. There are common areas at the end of each wing and at the entrance.

LPA conducted the annual at the same time as Rosewood Care Center 517003766, with the permission from Administrator Angie Karis and Administrator Rebecca Butler from Rosewood Care Center.

During this visit LPA toured the facility with Administrator Angie Karis and Administrator Rebecca Butler from Rosewood Care Center.

Multiple topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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