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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003009
Report Date: 03/20/2024
Date Signed: 03/20/2024 01:35:40 PM

Document Has Been Signed on 03/20/2024 01:35 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: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: 4DATE:
03/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Geri PatawaranTIME COMPLETED:
01:45 PM
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On 3/20/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with the administrator .

LPA conducted a case Management visit to observe R1 for whom the licensee is in process of a exception request.
LPA and administrator discussed the exception request and specific documents that remain to be submitted.

R1 is currently receiving needed assistance.

As a result of today’s inspection, no deficiencies were noted.


Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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