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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700395
Report Date: 03/26/2024
Date Signed: 03/26/2024 02:58:35 PM


Document Has Been Signed on 03/26/2024 02:58 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: 5DATE:
03/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Daisyree Tacandong, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with caregiver Eric and spoke with Administrator Daisyree Tacandong over the phone.

LPA arrived to ensure resident bedroom had a locking mechanism on the backdoor. Locking mechanism was present and working. Facility received an updated fire clearance for 6 bedridden residents. LPA provided administrator with an updated license reflecting changes.

No deficiencies cited during today's inspection.

Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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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