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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700112
Report Date: 05/18/2022
Date Signed: 05/18/2022 01:43:15 PM


Document Has Been Signed on 05/18/2022 01:43 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ALDER GROVE SENIOR LIVINGFACILITY NUMBER:
312700112
ADMINISTRATOR:TAN, CLIFFORDFACILITY TYPE:
740
ADDRESS:639 SHOCKLEY ROADTELEPHONE:
(650) 281-6612
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 5DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Frances LunaTIME COMPLETED:
02:15 PM
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On 5/18/2022 LPA Tryon visited the facility to do an annual visit. LPA had done a self-screening before the visit, took temperature, etc, LPA signed in at the door and screened. LPA met with staff Frances (Frankie ) Luna. . LPA also spoke with Administrator Clifford Tan by phone during the visit.

LPA reviewed the infection control domain of the CARES Tool.

LPA also toured the house including common areas, kitchen, dining room, bedrooms, bathrooms, storage, etc. Food supplies look to be of good quality and variety and there is plenty of food. The house was clean, nicely furnished, and in good condition. Smoke detectors are installed and functioning.
There is adequate supply of COVID masks, gloves, gowns, sanitizer etc.

At this time there appear to be no deficiencies.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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