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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002819
Report Date: 01/28/2022
Date Signed: 01/28/2022 04:26:00 PM

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:BRIDGEWAY SENIOR CARE, LLCFACILITY NUMBER:
315002819
ADMINISTRATOR:JACKSON, SAYEHFACILITY TYPE:
740
ADDRESS:313 WORDSWORTH COURTTELEPHONE:
(916) 893-3099
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
01/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sayeh JacksonTIME COMPLETED:
04:00 PM
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LPA Tryon visited the facility on 1/28/22 to conduct a pre-licensing visit. Prior to the visit LPA did a COVID self-screening and temperature check. LPA wore an N95 mask as per current policy.
LPA met with applicant Sayeh (Shay) Jackson.

LPA toured the house including kitchen, living area, bathrooms, bedrooms, hallways, storage, yard. The facility has smoke detectors and carbon monoxide detector as required.

The facility has adequate supplies, bedding, linens, food supply of 2 days perishable and 7 days non-perishable, cleaners, PPE, etc.

The facility appears to be clean, well-furnished, and in good condition.

LPA reviewed the Inspection Tool for pre-licensing visits.

At this time, the facility appears to be in compliance with regulations.

A Component III of the RCFE Orientation is not necessary, as the applicant has another RCFE facility and has recently completed the orientation.

The facility appears in compliance and report will be forwarded to the Central Application Unit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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