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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700815
Report Date: 05/18/2023
Date Signed: 05/18/2023 10:34:01 AM

Document Has Been Signed on 05/18/2023 10:34 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:PRIME ADULT DEVELOPMENT INCFACILITY NUMBER:
312700815
ADMINISTRATOR:CHENKO, TANYAFACILITY TYPE:
775
ADDRESS:5935 PACIFIC STREETTELEPHONE:
(916) 740-5577
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 30CENSUS: 23DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tanya Chenko, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Tanya Chenko during today's inspection. During today's inspection there were 23 clients attending program.

LPA toured the facility with the administrator. LPA observed common activity rooms, kitchen area, and bathrooms. Emergency exit was clear and accessible. In the areas toured no immediate health, safety, or personal rights violations were observed. The facility appeared to be clean and free from odors. There is a locked area for toxins and clients bring their own lunch to program.

LPA reviewed 3 client files and 3 staff files. Facility does not have clients that require medication services. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid and CPR certificates and training is being completed.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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