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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 576804173
Report Date: 07/15/2024
Date Signed: 07/15/2024 12:03:22 PM


Document Has Been Signed on 07/15/2024 12:03 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:GRAND RIVER VILLAFACILITY NUMBER:
576804173
ADMINISTRATOR:PAZ, DIANAFACILITY TYPE:
740
ADDRESS:509 MICHIGAN BLVDTELEPHONE:
(916) 373-1591
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:43CENSUS: DATE:
07/15/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Diana Paz & Mark CiminoTIME COMPLETED:
11:35 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 43
Census (if any clients in care): 27
COMP II Participants: Diana Paz, admin; Mark Cimino, member
Interview Method: Telephone interview

On July 15, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program

2. Medication Storage; locations of meds, fire drills

3. Transportation; filling current vacancies

4. Pre Licensing inspection readiness

SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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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