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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
577000418
Report Date:
01/13/2023
Date Signed:
01/13/2023 03:37:29 PM
Document Has Been Signed on
01/13/2023 03:37 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
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
GRAND RIVER CARE CENTER-WEST
FACILITY NUMBER:
577000418
ADMINISTRATOR:
PAZ, DIANA
FACILITY TYPE:
740
ADDRESS:
509 MICHIGAN BOULEVARD
TELEPHONE:
(916) 373-1591
CITY:
WEST SACRAMENTO
STATE:
CA
ZIP CODE:
95691
CAPACITY:
30
CENSUS:
22
DATE:
01/13/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:10 PM
MET WITH:
Diana Paz, Administrator
TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to amend a 9099-D from Complaint #21-AS-20221004190046 and review POC with Administrator Diana Paz.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Jill Nakagawa
TELEPHONE:
707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE:
01/13/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/13/2023
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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