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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
535002723
Report Date:
01/11/2024
Date Signed:
01/11/2024 11:23:08 AM
Document Has Been Signed on
01/11/2024 11:23 AM
- 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:
SHASCADE TRINITY SERVICES
FACILITY NUMBER:
535002723
ADMINISTRATOR:
MARTIN, MELISSA
FACILITY TYPE:
775
ADDRESS:
171 MASONIC AVE
TELEPHONE:
(530) 623-6881
CITY:
WEAVERVILLE
STATE:
CA
ZIP CODE:
96093
CAPACITY:
30
CENSUS:
67
DATE:
01/11/2024
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
10:45 AM
MET WITH:
Ariana Cravns
TIME COMPLETED:
11:40 AM
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On 01/11/2024 Licensing Program Analysts (LPAs) Ivan Avila and Jaynae Boyles arrived at the facility andto interview clients regarding a complaint in a different location. The issues do not involve this facility.
No deficiencies cited.
SUPERVISORS NAME
:
Anthony Perez
LICENSING EVALUATOR NAME
:
Ivan Avila
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/11/2024
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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