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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 295002148
Report Date: 05/23/2023
Date Signed: 05/24/2023 07:46:29 AM

Document Has Been Signed on 05/24/2023 07:46 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:LAKE WILDWOOD MANORFACILITY NUMBER:
295002148
ADMINISTRATOR:LOVE, MARY VBFACILITY TYPE:
740
ADDRESS:17802 SILVER PINE DRIVETELEPHONE:
(530) 432-7788
CITY:PENN VALLEYSTATE: CAZIP CODE:
95946
CAPACITY: 6CENSUS: 2DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mary LoveTIME COMPLETED:
05:00 PM
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On 5/23/2023 LPA Tryon visited the facility to complete an annual review. LPA was greeted by staff Danny, who contacted licensee Mary Love. She arrived a short time later.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, laundry, storage, outside area.

The house is clean, nicely furnished, has appropriate furnishings as per the regulations. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies, appear to be of good quality.
The facility has medications centrally stored and locked.
Facility has adequate supplies of cleaners, hygiene products, PPE, etc.
No hazards are noted.
Smoke detectors are functional, carbon monoxide detector installed, fire extinguishers present and charged.
Land line phone available.
Beds have appropriate furnishings, bedding, etc.

LPA reviewed the CARE Tool with licensee. Emergency and disaster plans available, Infection control plan etc.

At this time , the home appears to be in substantial complaince with the regulations. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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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