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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005926
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:37:41 PM


Document Has Been Signed on 05/19/2023 04:37 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: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: 4DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Stanford Madriaga, AdministratorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual required – 1 yr. inspection on 5/19/2023 and met with Administrator, Stanford Madriaga. There are 4 residents living in the home. There were 3 staff present at the time of inspection.

LPA toured the facility at 2:35 PM and facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The home does not have any bodies of water and Administrator states that there are no weapons in the home. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored. Toxins are stored in a locked closet. There was a supply of hygiene products and paper products available for residents. Facility is equipped with auditory alarms at all exit doors. Bathrooms were equipped with necessary grab bars, non-slip floors/mats and paper towels. All bedrooms have lighting & appropriate furnishings.

File review was initiated. Resident and staff files were reviewed. Medication reviewed. Staff have required First Aid/CPR certificates expiring 2/6/25. Administrator Certificate for Administrator, Stanford Madriaga #6031652720 expires June 24, 2024. Required postings were observed.

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: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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