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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700888
Report Date: 04/27/2023
Date Signed: 04/28/2023 10:20:47 AM


Document Has Been Signed on 04/28/2023 10:20 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:RNCARE HOUSE @ EAST ROSEVILLEFACILITY NUMBER:
312700888
ADMINISTRATOR:ESTANTE, EDWARDFACILITY TYPE:
740
ADDRESS:484 CALDARELLA CIRCLETELEPHONE:
(916) 200-8067
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 4DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Licensee: Hazel EstanteTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ivan Avila and Licensing Program Manager (LPM) Lauren Crocker made an unannounced required 1-year annual inspection at the facility today on April 27, 2023. Met with caregiver Cindy Holman and Licensee Hazel Estante. During this visit a tour of the facility was conducted, a review of the resident and staff records was complete and a sample of the medications was reviewed. Due to time constraints an additional visit will need to be made to finalize this annual inspection.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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