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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
052700992
Report Date:
05/15/2024
Date Signed:
05/15/2024 03:48:46 PM
Document Has Been Signed on
05/15/2024 03:48 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 LIVING
FACILITY NUMBER:
052700992
ADMINISTRATOR/
DIRECTOR:
MARY MCCLURE
FACILITY TYPE:
740
ADDRESS:
1400 FOOTHILL VILLAGE DRIVE
TELEPHONE:
(805) 801-0404
CITY:
ANGELS CAMP
STATE:
CA
ZIP CODE:
95222
CAPACITY:
78
CENSUS:
67
DATE:
05/15/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:
Mary McClure
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 5/15/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Mary McClure and explained the purpose of today's visit.
The facility has 4 floors. The 4th floor is used for independent living. The 2nd and 3rd floors are for assisted living and the first floor is for dementia care. During the course of the visit LPA Jensen toured floors 1 through 3. LPA Jensen also toured the grounds. Due to time constraints this annual will require a continuation. An exit interview was conducted a copy of this report was provided.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Maja Jensen
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/15/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/15/2024
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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