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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700757
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:08:38 PM


Document Has Been Signed on 04/25/2024 04:08 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:ROCKLIN CARE HOMEFACILITY NUMBER:
312700757
ADMINISTRATOR:MAGDA, MARYFACILITY TYPE:
740
ADDRESS:6459 SONORA PASS WAYTELEPHONE:
(916) 872-1537
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 5DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mary Magda, LicenseeTIME COMPLETED:
03:30 PM
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On 4/25/2024 LPA Tryon visited the facility to do an annual visit. LPA met with Mary Magda.
LPA toured the house including common areas, kitchen, bedrooms, hallways, bathrooms, medication storage, food storage, garage, and yard. The home appears to be clean and nicely furnished. Smoke and carbon monoxide detectors installed and functioning. Fire extinguishers present and charged. Food supplies appear appropriate to meet the requirement of 2 days perishable and 7 days non-perishable. Food appears varied and fresh. Medications are centrally stored and locked. Bathrooms are in good condition, fixtures new, clean and functional.

LPA reviewed the CARE Tool with licensee. LPA reviewed 2 resident files and 2 staff files and completed review forms. Files contain appropriate documentation.
LPA interviewed 2 residents and completed interview forms.
LPA completed staff interview form with Mary Magda.

Administrator has completed all course work for the 2 year period and and submitted documentation and payment for renewed Admin. Certificate. Administrator is waiting for the CCL Administrator Certification Unit to review documentation and renew certificate. Proof of submission was shown during visit.

At this time, the home appears to be in substantial compliance with the regulations.

No deficiencies were cited at this visit. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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