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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003009
Report Date: 08/07/2024
Date Signed: 08/07/2024 04:04:08 PM

Document Has Been Signed on 08/07/2024 04:04 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/
DIRECTOR:
CZAKO, GERALDINE PATAWARANFACILITY TYPE:
735
ADDRESS:263 FIRESTONE DRIVETELEPHONE:
(916) 786-3860
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 4CENSUS: 4DATE:
08/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 8/7/24, Licensing Program Analysts (LPA) Kevin Mknelly and Graham Gunby, conducted a case management visit and met with caregiver Rose. The Administrator was notified and arrived to assist.

The department received a facility action report (FAR) from the Regional Center for a inspection completed by them on 7/11/24. The action report noted record keeping deficiencies under Title 17 for medication administration documentation, staff first aid and medication orders records.

LPA interviewed Administrator, Jerry Czako, and found that while the deficiencies noted did not entirely meet the program design, the licensee otherwise complied with CCLD requirements

As a result of today’s inspection, no deficiencies were noted. A technical violation advisory was issued for not adhering to the documentation requirements to the letter program design.


Report reviewed. Copy of report and provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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