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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701001
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:08:44 PM


Document Has Been Signed on 06/02/2022 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
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: 5DATE:
06/02/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Facility staff Ezra TernateTIME COMPLETED:
04:30 PM
NARRATIVE
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Post Licensing visit is conducted in 06/02/22 inspection.

See LIC809 for 06/02/22 Annual visit for details.
See LIC809D for deficiency cited during today's visit.

Exit interview done and copy of the report will be sent via e-mail due to printer issue.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/02/2022 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 312701001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited

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87305 Alterations to Existing Building or New Facilities
(b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.
This requirement is not met as evidenced by:
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Based on observation, the Licensee converted 2 bedrooms connected the garage and did not notify CCL or update facility sketch. No permits were obtained and a fire clearance has not been complete, which poses a potential health, safety or personal rights risk to persons in care.
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Lastly, the licensee shall submit a letter to CCL indicating the rooms connected to the garage will be for staff use or storage use only. POC shall be submitted by 06/30/22.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2