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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 12/04/2024
Date Signed: 12/04/2024 11:31:48 AM

Document Has Been Signed on 12/04/2024 11:31 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:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR/
DIRECTOR:		COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 5DATE:
12/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:16 AM
MET WITH:Staff, Sevrena MillerTIME VISIT/
INSPECTION COMPLETED:
11:46 AM
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 On 12/04/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a case management visit. LPA met with Staff, Sevrena Miller explain the purpose of the visit.

The purpose of the visit is to gather more information regarding a death report (LIC624A) Community Care Licensing (CCL) received on 12/02/24. LPA spoke with facility staff regarding the events leading up to resident, R1s death. Death report states that R1 passed away in the hospital on 11/30/24 after being sent out due change of condition on 11/27/24.

LPA requested a copy of R1's LIC602 and ID page.

This case is under review and Department will follow up as warranted. At this time, no deficiencies are cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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