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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310303287
Report Date: 02/16/2024
Date Signed: 02/29/2024 09:49:20 AM


Document Has Been Signed on 02/29/2024 09:49 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:ROSE GARDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
310303287
ADMINISTRATOR:ANDRADA, ROSALINDAFACILITY TYPE:
740
ADDRESS:12520 KILLARNEY WAYTELEPHONE:
(530) 823-8216
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:12CENSUS: 8DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Tito Andrada, Licensee;
Tito Andrada, Jr. Administrator		TIME COMPLETED:
05:00 PM
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.On 2/16/24 LPA Tryon visited the facility to do an annual visit using the Care Tool. LPA met with Administrator Tito Andrada. The facility currently has 8 residents.

LPA toured the facility including common areas, kitchen, dining room, bedrooms, hallways, bathrooms, storage. The home is clean and in good repair. Smoke detectors and carbon monoxide detectors installed, fire extinguishers present and charged. There are adequate food supplies, PPE, cleaners, and other supplies. Medications centrally stored and locked.

LPA reviewed 3 staff files and -- resident files. Files appear to include required documentation. LPA interviewed one staff and 3 residents.

LPA reviewed the CARE Tool with Administrator.

At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were cited.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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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