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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700425
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:04:38 PM

Document Has Been Signed on 03/19/2024 03:04 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:PLACER STARCAREFACILITY NUMBER:
312700425
ADMINISTRATOR:BALAS-IRIMESCU, DAMIANAFACILITY TYPE:
740
ADDRESS:6814 CAMBORNE WAYTELEPHONE:
(916) 412-2758
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 5DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Damiana Balas-IrimescuTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday March 19, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (5) and staff files (3). All resident and staff files contained the required paperwork.

LPA Parks and Administrator Damiana toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, and backyard. In the areas toured, there were no health or safety violations observed.

Facility was clean and well organized. Facility has PPE supply on hand. First aid kit is fully stocked. All required posting were observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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