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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005554
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:05:37 PM


Document Has Been Signed on 04/22/2024 12:05 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:EL DORADO HILLS SENIOR CAREFACILITY NUMBER:
097005554
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2904 TAM O'SHANTER DRIVETELEPHONE:
(916) 933-0107
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 0DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Lenore AlexiusTIME COMPLETED:
12:05 PM
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On 04/22/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to conduct an annual visit . LPA met with Facility Administrator, Lenore Alexius and explained the purpose of the visit.

Facility has been non-operational for a few weeks due to a facility cosmetic upgrade.

Facility is scheduled to reopen within the next few weeks.

The files of 2 residents, that temporarily reside at a sister facility, were reviewed. Files contained the required paperwork. The files of 2 staff members contain the required training and paperwork.

Administrator / Licensee shall contact Community Care Licensing upon reopening.

No deficiencies are being cited as a result of todays inspection.

LPA requested a copy of the LIC500, 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 left with Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
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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