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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001898
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:17:50 PM


Document Has Been Signed on 02/14/2024 02:17 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:RESIDENCE HEALTHCARE-RCFEFACILITY NUMBER:
315001898
ADMINISTRATOR:ASHBURN, DARRINFACILITY TYPE:
740
ADDRESS:133 VALLEYWOOD WAYTELEPHONE:
(916) 788-4195
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 6DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Darrin AshburnTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/14/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with the licensee and explained the purpose of the visit. Administrator and Licensee were present to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is clean and well maintained. Resident care needs appear to be met with appropriate staffing.

LPA reviewed 6 resident files and 2 staff files. Files are complete and up to date.

No deficiencies are being cited as a result of todays inspection.


Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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