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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700466
Report Date: 04/10/2024
Date Signed: 04/10/2024 09:34:04 AM


Document Has Been Signed on 04/10/2024 09:34 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, 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:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melissa Washington, AdministratorTIME COMPLETED:
09:40 AM
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Licensing Program Analyst(LPA) Bethany Mirlohi arrived to conduct an annual inspection. LPA met with Administrator Melissa Washington during today's inspection.

LPA toured the facility with Administrator. Currently there are no residents living at the facility. Administrator to inform LPA when first consumer is admitted.

No deficiencies cited during today's inspection.

Copy of report provided. Exit interview.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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