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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701001
Report Date: 05/25/2023
Date Signed: 05/25/2023 02:47:53 PM


Document Has Been Signed on 05/25/2023 02:47 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 6DATE:
05/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Daisyree Tacandong, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with administrator Daisyree Tacandong during today's inspection.

LPA toured the facility with administrator. LPA observed resident rooms, staff rooms, common areas, and kitchen area.

Administrator did not have staff files for LPA to review. LPA will return on a later date to review documents.

No deficiencies are being cited today.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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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