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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700224
Report Date: 10/09/2024
Date Signed: 10/09/2024 02:30:52 PM


Document Has Been Signed on 10/09/2024 02:30 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:JOANN'S HOME CAREFACILITY NUMBER:
312700224
ADMINISTRATOR:ANTONE, DAVID RUBENFACILITY TYPE:
740
ADDRESS:6596 ROSE BRIDGE DRIVETELEPHONE:
(916) 771-4901
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:David AntoneTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/9/24 to conduct a Annual Inspection utilizing the CARE inspection tool. Caregiver informed Administrator (Admin) that LPA was present. Admin arrived to assist with the visit the visit.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed 3 resident files. Files are complete.

LPA reviewed 2 staff files. Files complete for forms and training.

Licensee will submit the following records for updating their facility file: LIC 500, roster roster, liability insurance and infection control plan.

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

Exit interview conducted. Report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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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