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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002920
Report Date: 07/28/2022
Date Signed: 07/29/2022 01:33:02 PM


Document Has Been Signed on 07/29/2022 01:33 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:AIM ELDERLY CAREFACILITY NUMBER:
315002920
ADMINISTRATOR:HARDOSUBROTO, ALFONSUSFACILITY TYPE:
740
ADDRESS:1397 SUN TREE DRTELEPHONE:
(530) 305-8766
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: DATE:
07/28/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Alfonsus HardosubrotoTIME COMPLETED:
01:26 PM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Change of ownership
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Alfonsus Hardosubroto

Interview Method: Telephone interview
On July 28, 2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Bethany HunterTELEPHONE: (916) 651-3571
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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