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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 04:09:55 PM


Document Has Been Signed on 06/02/2022 04:09 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Facility Staff Ezra TernateTIME COMPLETED:
04:30 PM
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Licensing Program Analyst Talwinder Bains arrived at the facility unannounced on 06/02/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with facility staff ,Ezra Ternate , and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by facility staff before entry to facility.

Upon arrival, LPA spoke to facility administrator Daisyree Tacandong over facility phone and she gave permission to complete annual inspection for today with facility staff Ezra Ternate since she is unable to come because she is going to work today. LPA and facility staff Ezra toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, five bedrooms , two bathrooms, medication closet , staff break room, garage, laundry room and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff Ezra completed the infection control domain together.

During facility tour, LPA observed that 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.As a result of today's inspection, deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 87305(b). Deficiencies are listed on 809-D.


Appeal rights provided. Exit interview conducted and copy of report will be sent to facility 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)
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