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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005412
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:16:44 PM

Document Has Been Signed on 03/07/2024 03:16 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:VIRGINIA DENISE COUNTRY HOMEFACILITY NUMBER:
347005412
ADMINISTRATOR:FERMO, AILEENFACILITY TYPE:
740
ADDRESS:2305 VIRGINIA DENISE LANETELEPHONE:
(916) 813-0460
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 4DATE:
03/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administraor- Aileen FermoTIME COMPLETED:
03:15 PM
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On 03/06/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year annual inspection. LPA met with Administrator Aileen Fermo and explained the purpose of the visit.

LPA and Administrator discussed that the annual is due for their facility Cantor- Fermo Residential Home #2 which at the front of the street. As this annual is not until July.

Administrator informed LPA she will meet LPA at the other facility.

LPA vacated the premises.

Exit interview, a copy of report was provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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