<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700212
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:17:53 PM

Document Has Been Signed on 01/14/2025 04:17 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:ROCK CREEK SENIOR CAREFACILITY NUMBER:
312700212
ADMINISTRATOR/
DIRECTOR:		BALINT, PAVELFACILITY TYPE:
740
ADDRESS:6408 MENDEZ CREEK CTTELEPHONE:
(916) 899-6298
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Carmenuta BalintTIME VISIT/
INSPECTION COMPLETED:
04:27 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka, conducted this unannounced annual visit. This facility has six private resident rooms. One private room is to the right of the main entrance. The rest of the resident rooms and two common bathrooms are located to the left of the facility down a hallway. The entrance of the facility leads to an open floor plan that has the kitchen, dining, and sitting area. There is a locked storage closet for medications and records in the kitchen area. There locked laundry room and caregiver room in a nook area in the kitchen. The garage is only accessible from the outside and is used for storage. The backyard was inspected. There is a gate on both sides of the facility.

-two staff records were reviewed
-three resident records were reviewed
-multiple topics were discussed


The following shall be updated and submitted to Community Care Licensing by the end of the month:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility



No citations were issue
Troy OrdonezTELEPHONE: (916) 263-4700
Kerry HiratsukaTELEPHONE: (916) 591-0210
DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1