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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002963
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:25:34 PM

Document Has Been Signed on 10/21/2022 12:25 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:NORTHPARK MANORFACILITY NUMBER:
315002963
ADMINISTRATOR:IACOB, GEORGETAFACILITY TYPE:
740
ADDRESS:1525 NORTHPARK DRTELEPHONE:
(916) 849-7327
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 0DATE:
10/21/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee/Administrator Georgeta IacobTIME COMPLETED:
11:50 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
Method: Telephone call with RO
COMP II Participants: Georgeta Iacob (Corporate Board Member and Administrator)
On October 21, 2022, applicant/administrator participated in COMP II via telephone call with the analyst at CAB. 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 Title 22. Component II was successfully completed.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program

2. Staff qualifications and responsibilities

3. Applicant and Administrator qualifications

4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions

5. Grievances, Complaints, Community resources

6. Physical plant, food service

7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Diamond Law
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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