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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001756
Report Date: 05/11/2023
Date Signed: 05/11/2023 09:45:07 AM


Document Has Been Signed on 05/11/2023 09:45 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:COMPASS ROSEFACILITY NUMBER:
045001756
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2750 SIERRA SUNRISE TERRACETELEPHONE:
(530) 774-2705
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:48CENSUS: 26DATE:
05/11/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Cliff Keene and Pomali ThitphanethTIME COMPLETED:
09:50 AM
NARRATIVE
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LPA Hiratsuka, conducted this unannounced case management- legal/non-compliance visit.

LPA toured with Mel Rabauliman, Resident Service Coordinator. LPA finished the visit with Cliff Keene and Pomali Thitphaneth. LPA also reviewed staff training.

A couple topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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