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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002963
Report Date: 11/20/2024
Date Signed: 11/20/2024 01:34:00 PM

Document Has Been Signed on 11/20/2024 01:34 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NORTHPARK MANORFACILITY NUMBER:
315002963
ADMINISTRATOR/
DIRECTOR:
IACOB, GEORGETAFACILITY TYPE:
740
ADDRESS:1525 NORTHPARK DRTELEPHONE:
(916) 849-7327
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Teresa CarterTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to conduct an annual inspection. LPA met with Teresa Carter during today's inspection.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed six (6) resident rooms and two (2) common area bathrooms. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 113 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed five (5) resident files, one (1) staff file and two (2) resident medications. Facility has a current copy of certificate of liability insurance and LPA obtained a copy.

As a result of this visit, no deficiencies were cited.

Exit interview was conducted with Administrator. A copy of this report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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