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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700445
Report Date: 05/14/2024
Date Signed: 05/14/2024 01:55:27 PM

Document Has Been Signed on 05/14/2024 01:55 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:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
092700445
ADMINISTRATOR/
DIRECTOR:		WALL, ALISON MFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 64CENSUS: 26DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Business Office Manager Bridget BotezTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on 5/14/24 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (5) and staff (5) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA and Business Office Manager Bridget Botez toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, kitchen, hallways, memory care dining room, and memory care common areas. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.

Exit interview conducted. A copy of this report was printed and given to Business Office Manager.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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