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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700466
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:24:16 PM


Document Has Been Signed on 05/18/2023 03:24 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:ELEGANCE MANORFACILITY NUMBER:
312700466
ADMINISTRATOR:WASHINGTON, MELISSAFACILITY TYPE:
740
ADDRESS:6448 GARLAND WAYTELEPHONE:
(916) 899-5163
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Melissa Washington, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to complete annual inspection. LPA met with Administrator Melissa Washington.

Currently the facility does not have residents care. LPA toured the facility with administrator. LPA observed resident rooms, common spaces, garage, and kitchen area. Administrator agrees to inform LPA when they accept a resident.

No deficiencies cited during today's inspection.

Exit interview.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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