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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002916
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:22:00 PM


Document Has Been Signed on 04/18/2024 03:22 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: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: 3DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Aileen Mendoza, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA spoke with Administrator Aileen Mendoza over the phone. Currently there are 3 residents that reside at the facility.

LPA arrived to the facility to discuss their vendorization with Regional Center. LPA spoke to the administrator concerning regulations and forms that will need to be in resident files. No health and safety violations observed. No deficiencies cited during today's inspection.

Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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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