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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701001
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:23:58 PM

Document Has Been Signed on 07/06/2022 12:23 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:
07/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Daisyree TacandongTIME COMPLETED:
12:40 PM
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On 07/06/22, Licensing Program Analysts (LPAs) Talwinder Bains and Kerry Hiratsuka came to the facility to do a follow up visit regarding POC from Annual /post licensing visit conducted on 06/02/22 and met with Administrator, Daisyree (Daisy) Tacandong. Facility currently does not have any COVID-19 positive cases. LPAs wore surgical masks while in the facility. LPAs were screened by facility staff upon entry.

On 06/02/22, during facility tour, LPA observed the garage was converted into two bedrooms and Community Care Licensing Division (CCLD) was not notified. Administrator admitted no permits were obtained nor was there a fire clearance done. Because Administrator did not have permits, submit the changes to CCLD, and no fire clearance was obtained, deficiencies were cited pursuant to California Code of Regulations, Title 22, Section 87305(b) with POC date 06/30/22.

On 06/06/2022, Administrator sent documents and updated facility sketch to LPA Bains via e-mail and stated that these two rooms in the garage will be used only for staff break room and storage area and they will not be used for residents in any manner. After receiving these documents and facility plan ,CCLD ordered a fire clearance.

A Roseville Fire inspector visited the facility and inspected break room and storage room in the garage on 06/13/22 and advised Administrator to reach out to Roseville City to obtain a building permit for these 2 rooms in garage. On 06/14/22, an inspector Roseville from City Planning came out to do inspection for the two rooms in the garage and they were denied.



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SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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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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
VISIT DATE: 07/06/2022
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Continued from 809-----

Today's visit, LPAs met with Administrator. The two rooms have not been removed. Administrator stated she was told by City Planning that she may appeal to the City Council. She has not yet as of today. She shall submit to LPA Bains by 07/30/2022, a written plan on how and when she will appeal to the City Council. She shall also submit a copy of her appeal to LPA Bains within 24 hours of submitting it to the City.

THE ROOMS IN THE GARAGE SHALL NOT BE USED FOR ANYTHING. CCLD has the authority to conduct random checks to ensure the rooms are not being used for anything until the issue is resolved with the City. If any of the random checks finds the rooms in use there shall be a deficiency cited because the rooms do not have permits and if a staff person is found sleeping in the room an immediate civil penalty shall be issued and shall accrue.

No deficiencies cited today. Exit interview conducted and copy of this report left at facility.



SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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