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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701001
Report Date: 06/03/2021
Date Signed: 06/04/2021 03:00:22 PM

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:A1 SENIOR CARE 2FACILITY NUMBER:
312701001
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:2040 SYMPHONY AVETELEPHONE:
(916) 472-4543
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
06/03/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Daisyree TacandongTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility announced on 06/03/2021 to conduct an announced prelicensing visit. LPA met with Applicant/Administrator Daisyree Tacandong, and explained the purpose of the visit. Prior to initiating the prelicensing visit, 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; contacted applicant and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Administrator at the front door.
This facility has a fire clearance for all non-ambulatory. The main entrance opens to a small foyer. To the right of the main entrance is a short hallway that has two private resident rooms and a full bathroom. Past the first hallway on the right is a third private resident room, locked door to the laundry room, and a small office nook. To the left of the main entrance is a door leading to the garage, and a forth private room that has a locked door leading to the kitchen. Across the main entrance is a double-door that leads to the main common area and the fifth resident room which is shared. The shared resident room is on the right, has an exit to the outside, and a full private bathroom. There is also a second door leading to the laundry room. There are locked cabinets for medications and sharp knives in the kitchen.
The backyard was inspected. There is a covered patio, and a fire place. The fire place is disabled. The gate is on the same as the garage.

LPA waived the component III orientation because Administrator already operates another facility. Multiple topics were discussed during this visit.

This facility meets regulations. LPA is going to submit this report to the applications specialist.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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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