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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:50:06 PM

Document Has Been Signed on 10/05/2023 03:50 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 78CENSUS: DATE:
10/05/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Mary McClureTIME COMPLETED:
04:00 PM
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On 10/5/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to an unrelated manner. During the course of the visit, The Executive Director Mary McClure requested a case management to seek general guidance and technical assistance in the areas of dementia care, levels of care and evictions.

LPA Jensen provided technical assistance and discussed the above listed items. LPA Jensen also met with two responsible parties for Resident 1 (R1) and discussed observation of the resident, rate increases due to a change in the level of resident care, prohibited items for dementia care residents and eviction requirements.

No citations were issued as a result of this care management. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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