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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005554
Report Date: 06/06/2024
Date Signed: 06/06/2024 10:54:38 AM


Document Has Been Signed on 06/06/2024 10:54 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, 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:
06/06/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Lenore AlexiusTIME COMPLETED:
10:53 AM
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LPA Lavinia Muscan, arrived on 6/6/24 to conduct a health and safety check in response to facility filing for bankruptcy. Today, LPA checked the food supply and did a brief walk through. No concerns noted.

No citations were cited during today's visit.

Exit interview conducted. Copy of report left at facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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