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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002985
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:46:47 PM

Document Has Been Signed on 04/17/2024 03:46 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:VILLA ELISA-FOLSOMFACILITY NUMBER:
345002985
ADMINISTRATOR/
DIRECTOR:		WORSFOLD, MAGGIE POSADASFACILITY TYPE:
740
ADDRESS:124 HILLSWOOD DRIVETELEPHONE:
(916) 932-4461
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:28 PM
MET WITH:Caregiver, Agi SautuTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On April 17, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to see if the accusation was posted in the facility in a prominent area. LPA met with caregiver, Agi Saut and explained the reason for the visit.

The licensee had the accusation posted where the rest of the facilities posters are, In the kitchen. Caregiver, called the licensee. however he did not answer.
Per California Code of Regulation Title 22, no citations were issued.

An exit interview was conducted and a copy was sent to facilities email address.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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