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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002771
Report Date: 03/22/2023
Date Signed: 03/22/2023 02:45:29 PM

Document Has Been Signed on 03/22/2023 02:45 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:OLIVE CITY CARE HOMEFACILITY NUMBER:
525002771
ADMINISTRATOR:MENDROS, MARITESFACILITY TYPE:
740
ADDRESS:423 WALNUT STREETTELEPHONE:
(530) 824-2845
CITY:CORNINGSTATE: CAZIP CODE:
96021
CAPACITY: 6CENSUS: 6DATE:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Marites and Erico MendrosTIME COMPLETED:
01:55 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing one.

This facility has six private resident rooms and three rooms used for staff and storage. There are two full common bathrooms and three of the resident rooms have their own private bathrooms. There is one common half bathroom.

Discussed are floor plan options and capacity options.

Several other topics discussed.

No deficiencies cited.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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