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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002631
Report Date: 12/04/2024
Date Signed: 12/04/2024 10:56:44 AM

Document Has Been Signed on 12/04/2024 10:56 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AAVON CARE HOME #1FACILITY NUMBER:
585002631
ADMINISTRATOR/
DIRECTOR:		BAL, JAGDEEPFACILITY TYPE:
735
ADDRESS:2058 MOSS GLEN LOOPTELEPHONE:
(530) 701-4037
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Jagdeep Bal and Benita Velenzuela LopezTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Benita Velenzuela Lopez. Licensee Jagdeep Bal arrived during this visit and completed the visit with LPA.

The main entrance opens into a small common area. There is an office area to the right of the main entrance. There is a private room to the right of the main entrance. To the left of the main entrance has a hallway leading to to three private bedrooms, laundry room, one full common bathroom, the largest of the three bedrooms has a full private bathroom and an exit to the outside, and a door leading to the garage. The back of the facility has the main common, dining, and kitchen area. There are locked cabinets for confidential information and medications.

Three staff records were reviewed
Two resident records were reviewed.




No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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