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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700253
Report Date: 01/08/2024
Date Signed: 01/10/2024 08:48:16 AM

Document Has Been Signed on 01/10/2024 08:48 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:ITV CARE HOMEFACILITY NUMBER:
312700253
ADMINISTRATOR:QUIPA, KARIZMAFACILITY TYPE:
735
ADDRESS:6064 CRATER LAKE DRIVETELEPHONE:
(916) 742-5232
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 4CENSUS: 3DATE:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Karizma QuipaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/8/24 to conduct a Required-1 Year Inspection utilizing the CARE inspection tool. Administrator arrived to assist with the inspection. Clients are at program.

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, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

Client and staff files reviewed and complete.

LPA received a copy of the client roster.

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

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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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