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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097003223
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:00:18 AM


Document Has Been Signed on 10/31/2023 11:00 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:PINE TREE VILLAFACILITY NUMBER:
097003223
ADMINISTRATOR:LYNN RELOZAFACILITY TYPE:
740
ADDRESS:3353 CIMMARRON ROADTELEPHONE:
(530) 672-9080
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:15CENSUS: 10DATE:
10/31/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Caregiver John MabbaguTIME COMPLETED:
11:15 AM
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LPA Lavinia Muscan, arrived on 10/31/23 to conduct a health and safety check in response to being notified the licensee passed away on 10/15/23. Today, LPA checked the food supply and did a brief walk through. No concerns noted.

No citations were cited during today's visit.

Exit interview conducted. Copy of report left at facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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