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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700395
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:54:37 PM


Document Has Been Signed on 01/30/2024 12:54 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:A1SENIOR CAREFACILITY NUMBER:
312700395
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:217 HINGHAM CTTELEPHONE:
(916) 740-7715
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Daisyree Tacandong, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a plan of correction visit. LPA met with Administrator Daisyree Tacandong during inspection.

LPA observed plan of corrections were corrected and cleared. Letter of clearance letters printed.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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