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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005926
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:51:53 PM


Document Has Been Signed on 11/03/2023 02:51 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:LAKE VIEW VILLAFACILITY NUMBER:
577005926
ADMINISTRATOR:MADRIAGA, STANFORDFACILITY TYPE:
740
ADDRESS:3865 COLLINS STREETTELEPHONE:
(916) 873-8633
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95691
CAPACITY:6CENSUS: 3DATE:
11/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:TIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection. There were 3 residents and 2 staff present at the time of inspection.

LPA Nakagawa found the facility clean and a comfortable temperature. There was one resident watching television in the living room. The other two residents were resting in their rooms.

All doors were free from obstructions and alarms for the doors were armed. Kitchen was clean and well-organized. Medication room was found to be in good order. LPA found 7-day pill containers in med room (empty) and reminded staff that medication must be stored in their original containers. Residents looked comfortable, clean and appropriately dressed.

The outdoor areas were well-kept and free of debris.

There were no deficiencies found at the time of inspection.
There were no citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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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