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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700728
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:07:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CLARA CARE HOME AT ROSEVILLEFACILITY NUMBER:
312700728
ADMINISTRATOR:KIM, OKKIFACILITY TYPE:
740
ADDRESS:602 FALCON WAYTELEPHONE:
(530) 771-7715
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 0DATE:
10/22/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Okki Kim TIME COMPLETED:
02:06 PM
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On 10/22/2021 at 1 PM, an Office Meeting was conducted on this day in the Sacramento North Regional Office via Microsoft Teams, due to COVID-19 precautions. The purpose of this Office Meeting was to discuss facility's renovation and possible closure. Present in the meeting was Licensing Program Manager (LPM) Troy Ordonez, Licensing Program Analyst (LPA) Sarena Keosavang, Administrator Okki Kim.

The facility is current being remodeled. The renovation started in July of this year. There are no residents at the facility. The facility do not plan on accepting any residents at this time.

Administrator stated the facility is currently going through the process of applying for a Congregate Living Facility Waiver through the Department of Public Health. Once the waiver has been approved by the Department of Public Health the facility plans to close Clara Care Home at Roseville.

At this time Administrator agrees that the facility will not accept any assisted living residents. Administrator agrees to contact LPA Keosavang once the waiver has been approved or denied by the Department of Public Health.

Administrator was advised that if the waiver is approved a final walk through is mandatory to close out the facility. It was also advised that fees are current and there are no outstanding balances.

An exit interview was conducted and a copy of this report will be emailed to Administrator. Administrator is to sign the report and email it back to LPA.



SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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