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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002966
Report Date: 12/20/2023
Date Signed: 12/20/2023 09:44:22 AM

Document Has Been Signed on 12/20/2023 09:44 AM - 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:AI MESIAS CAREFACILITY NUMBER:
315002966
ADMINISTRATOR:MESIAS, ROLANDFACILITY TYPE:
735
ADDRESS:1025 FORTUNA DRTELEPHONE:
(510) 358-5413
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 4CENSUS: 0DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Roland Mesias, AdministratorTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct the annual inspection. LPA met with Roland Mesias during today's inspection.

Currently there are no clients residing within the facility. LPA toured the facility with Administrator. LPA observed 4 clients rooms, staff room, kitchen, garage, and common areas.

Administrator agrees to inform LPA when 1st client is accepted to the facility. No deficiencies during today's inspection.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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