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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005926
Report Date: 07/22/2024
Date Signed: 07/22/2024 11:25:43 AM


Document Has Been Signed on 07/22/2024 11:25 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
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:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stanford Madriaga, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual required – 1 yr. inspection on 07/22/2024 and met with Administrator, Stanford Madriaga. There are 3 residents living in the home. There were 2 caregivers present at the time of inspection.

LPA toured the facility at 9:00 AM and facility was found to be clean and at a comfortable temperature with all exits free from obstruction. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food in the kitchen refrigerator was properly stored and dated. Toxins are stored in closet in the locked laundry room. There was a supply of hygiene products and paper products available for residents. Facility is equipped with auditory alarms at all exit doors, and on the gates in the back yard. Bathrooms were equipped with necessary grab bars, non-slip floors/mats and paper towels. All bedrooms have lighting & appropriate furnishings, including plenty of linens. Resident rooms were clean and well-lit and residents were clean, appropriately dressed and satisfied with their care. The facility had one fire extinguisher, fully charged and last serviced on 5/21/2024. There were 3 carbon monoxide detectors which were operational at the time of inspection. There were 6 smoke detectors, which were tested and operational.

Resident and staff files were reviewed and found to be complete Staff have required First Aid/CPR certificates, and required annual training.

No deficiencies found at the time of inspection. No citations issued.

Exit interview conducted with Administrator, Stanford Madriaga.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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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