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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700805
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:49:58 PM

Document Has Been Signed on 12/06/2023 03:49 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NORTHERNCARE FACILITYFACILITY NUMBER:
342700805
ADMINISTRATOR:WOODWARD, ROSE BALUROFACILITY TYPE:
740
ADDRESS:5016 WATERBURY WAYTELEPHONE:
(530) 762-8199
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 6DATE:
12/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Rose Baluro Woodward, AdministratorTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Rose Baluro Woodward, to obtain a signature relative to amending a report for an inspection conducted on 11/16/2023.

Signature was obtained for amended document during visit.

An exit interview was conducted with the Administrator. A copy of this report was provided to the facility. Signature acknowledges receipt of this report.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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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