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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003019
Report Date: 12/19/2023
Date Signed: 12/19/2023 12:08:07 PM


Document Has Been Signed on 12/19/2023 12:08 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:A1 SENIOR CARE 3FACILITY NUMBER:
315003019
ADMINISTRATOR:PACATANG, BARBRAFACILITY TYPE:
740
ADDRESS:421 ASHWOOD WAYTELEPHONE:
(279) 336-1702
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 6DATE:
12/19/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Daisyree TasandongTIME COMPLETED:
12:30 PM
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On Tuesday December 19, 2023, Licensing Program Analyst Melissa Parks arrived to conduct an unannounced post licensing inspection.

LPA reviewed 6 resident and 2 staff files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA toured the facility with Licensee Daisyree. The following areas were inspected: resident rooms, resident bathrooms, kitchen, garage, and common area. LPA reviewed facility's Medication Administration Record. Facility has a fully stocked first aid kit.

No deficiencies cited. An exit interview conducted. A copy of this report was emailed.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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