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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003009
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:16:26 PM

Document Has Been Signed on 05/18/2023 03:16 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:FIRESTONE HOME LLCFACILITY NUMBER:
315003009
ADMINISTRATOR:CZAKO, GERALDINE PATAWARANFACILITY TYPE:
735
ADDRESS:263 FIRESTONE DRIVETELEPHONE:
(916) 786-3860
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 4CENSUS: 3DATE:
05/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:CasregiverTIME COMPLETED:
03:30 PM
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 On 5/17/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced pre-licensing visit and met with caregiver. Licensee, Geraldine Patawaran was notified and arrived to assist with visit. Also in attendance was Fred Patawaran.

LPA toured Physical Plant, Food Service, Common Areas, Bedrooms, Bathrooms, Kitchen and Medication Storage. Fire extinguisher is current and First Aid is fully stocked. Kitchen was clean and good repair. Licensee has knowledge of (7) seven (2) two day supply of non-perishable and perishable, and required emergency shelter in place supplies. Rooms inspected have appropriate items and are in good repair. Water temperatures was measured and found to be within regulatory requirements. LPA observed centrally stored medications and toxins are to be kept locked and inaccessible to residents. Staff and resident files are to be set up to contain required documents.
Facility will accept total capacity of four (4) adult residents. LPA observed this facility appears to be clean, safe, and secured. All common areas appear to be free from hazards, clean and in good repair. As of this date, the Department has received the fire clearance.

During this visit, this facility is in substantial compliance and meets the minimum requirements for a ARF license.

Component III was completed.
Application is pending further review.

Report reviewed and copy provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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