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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002920
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:01:08 PM


Document Has Been Signed on 09/28/2022 03:01 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 6DATE:
09/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Alfonsus Hardosubroto- Administrator TIME COMPLETED:
03:10 PM
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On 09/28/2022, Licensing Program Analyst (LPA) Sarena Keosavang conducted an Prelicensing inspection. LPA met with Administrator, Alfonsus Hardosubroto, and explained the purpose of the visit. LPA were screened by Administrator prior to entering the facility. LPA wore a surgical mask while at the facility.

The facility has six (6) bedrooms and three (2) bathrooms. LPA observed the common areas, kitchen area, bedrooms, and bathrooms. LPA observed knives/ sharps area were locked in the kitchen cabinets. Toxic and cleaning supplies are locked underneath the sink cabinet located in the kitchen. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. LPA observed required furniture, and lighting throughout the facility. Bathrooms are clean, sanitary, and in good repair. The hot water temperature was measured in the kitchen at 106 degrees Fahrenheit. First aid kit was completed with bandages, tweezers, scissors, and thermometer. LPA observed centrally stored medications area were locked and inaccessible. Outdoor passageways were free of obstruction.

LPA observed one (1) fire extinguisher, smoke detectors, and carbon monoxide detectors in the facility. Licensing complaint poster are posted as required.

Component III presentation conducted with administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

An exit interview was conducted with administrator and a copy of this report will be provided to the facility via email.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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