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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001963
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:52:54 PM


Document Has Been Signed on 06/20/2024 02:52 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: 60DATE:
06/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Angie KarisTIME COMPLETED:
03:00 PM
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LPA Hiratsuka conducted this unannounced case management visit. This is in response to one resident who physically attacked another resident and the staff on duty 06/15/2024.

LPA interviewed Administrator Angie Karis. The resident and staff who were assaulted had minor injuries and are doing well. The resident who attacked the others was removed from the facility by the police, taken to the hospital, and discharged by the conservator. LPA was here to get information about staff supervision and did not observe any lack of supervision on the part of the staff.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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