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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
585920044
Report Date:
06/26/2024
Date Signed:
06/26/2024 12:37:27 PM
Document Has Been Signed on
06/26/2024 12:37 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
PAGE MANOR
FACILITY NUMBER:
585920044
ADMINISTRATOR/
DIRECTOR:
PAGE, KAI
FACILITY TYPE:
735
ADDRESS:
806 JOHNSON AVE
TELEPHONE:
(530) 743-4373
CITY:
MARYSVILLE
STATE:
CA
ZIP CODE:
95901
CAPACITY:
5
CENSUS:
5
DATE:
06/26/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:
Kai Page
TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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LPA Hiratsuka conducted an unannounced annual visit. LPA toured the facility with Administrator Kai Page.
This facility has a fire clearance for five ambulatory residents. This facility has four resident rooms and one staff room. The staff room has a full private bathroom. There are two full common bathrooms. One of the full common bathrooms also has the clothes washer and dryer in it. There is also an office that has locked cabinets for medications and has storage space in it. There is an ample supply of perishable and nonperishable food. There are two sheds in the backyard.
Two staff and two resident records were reviewed.
Several topics were discussed.
No deficiencies cited.
SUPERVISORS NAME
:
Troy Ordonez
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/26/2024
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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