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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 095002919
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:47:03 PM


Document Has Been Signed on 07/24/2023 01:47 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:PLEASANT CARE HOMEFACILITY NUMBER:
095002919
ADMINISTRATOR:SEPULVEDA, LINAFACILITY TYPE:
740
ADDRESS:4880 RIVENDALE RD.TELEPHONE:
(530) 647-2899
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY:6CENSUS: 2DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Lina SepulvedaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on 7/24/2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Muscan reviewed resident (2) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork and training. Staff have current first aid and CPR training.

LPA Muscan and Administrator toured the facility together to ensure the health and safety of clients in care. The areas toured included client rooms, bathrooms, kitchen, common areas and outside area. Water temperature is within the required range of temperatures. In the areas toured, there were no health or safety violations observed.

LPA requesting updated copy of LIC500, current liability insurance, and an updated copy of the LIC610E to be sent in to CCLD.

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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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