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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700728
Report Date: 03/23/2022
Date Signed: 03/23/2022 05:00:11 PM


Document Has Been Signed on 03/23/2022 05:00 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
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:
03/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Okki Kim TIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility on 3/23/2022 to conduct a Case Management Inspection proceeding the closure of the facility. LPA met with Administrator, Okki Kim, and explained the purpose of the visit. Prior to initiating the Case Management Inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and LPA completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA observed that there were no residents at the facility. LPA toured the interior and exterior of the facility. Areas toured include but are not limited to: common areas, four (4) residents bedrooms, three (3) bathrooms, kitchen, and backyard.

LPA received original License from Administrator at the facility. The facility will be closed in the system as of 03/23/2022.

Exit interview conducted and a copy of the report was sent to Administrator via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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