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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700888
Report Date: 04/17/2024
Date Signed: 04/17/2024 04:47:12 PM


Document Has Been Signed on 04/17/2024 04:47 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: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: 6DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Hazel EstanteTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/7/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with Administrator who assisted with the visit.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care.
Food supplies meet requirements. LPA advised hall light bulbs be replaced. LPA provided advisement.

LPA reviewed 6 resident files. Files are complete. LPA provided advisement.

LPA reviewed 2 staff files. Files are complete. LPA provided advisement.

LPA requested the following documents be submitted to update the facility file:
LIS 500, LIC 308s for staff responsible when admin is not present and Infection Control Plan

Licensee was notified of fees due by 4/30/24.

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


Exit interview conducted with licensee and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
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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