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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002916
Report Date: 12/09/2022
Date Signed: 12/09/2022 10:06:40 AM


Document Has Been Signed on 12/09/2022 10:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ROSEVILLE RESIDENTIALFACILITY NUMBER:
315002916
ADMINISTRATOR:MENDOZA, AILEEN MAEFACILITY TYPE:
740
ADDRESS:7048 CASTLE ROCK WAYTELEPHONE:
(916) 619-7673
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
12/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Aileen Mendoza and Truong HoangTIME COMPLETED:
10:15 AM
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LPA Hiratsuka, conducted this unannounced prelicensing visit. LPA wore a surgical mask during the visit and the applicants wore surgical masks.

This facility has a fire clearance for six bedridden residents. The main entrance opens to a common area. To the left of the common area is a short hallway that leads to a full common bathroom that is not going to be used to bathe residents in due to not being able to put grab bars in the shower/tub, the laundry room that has a door connecting to the a resident closet, the staff bedroom, and door leading to the garage. To the right of the main entrance is a hallway that leads to three resident rooms; two private and one shared. The two private rooms share a toilet and shower, but have a sink in each bedroom. The shared room in the same hallway has a full private bathroom. Past the first common area through a doorway leads to the main common area and kitchen. There is a short hallway on the left that leads to the second shared resident room that does not have an exit to the outside. The resident room has a full private bathroom and the bathroom connects to a very large closet that has a door that leads to the laundry room. The back common area has a door leading to the outside. Next to the kitchen there is a nook that is used for office space and has a door leading to the pantry. There are locked cabinets for files and medications. The backyard was inspected. There is a covered patio and the gate is on the same side as the garage.

Component III orientation was conducted.

This facility meets regulations. LPA is going to forward this report to the application specialist.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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