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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920031
Report Date: 07/12/2023
Date Signed: 07/12/2023 02:28:42 PM


Document Has Been Signed on 07/12/2023 02:28 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:PREMIUM SENIOR CARE HOMEFACILITY NUMBER:
315920031
ADMINISTRATOR:GEISTLINGER, DAVIDFACILITY TYPE:
740
ADDRESS:1419 TIFFANY CIRTELEPHONE:
(916) 595-5738
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 0DATE:
07/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator: David Geistlinger TIME COMPLETED:
03:00 PM
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On 07/12/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Administrator, David Geistlinger, and explained the purpose of the visit. There are currently no residents at the facility.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) residents' bedrooms and three (3) bathrooms. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, and properly maintained. The hot water temperature was observed at 106 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed at least a 2-day perishable and 7-day nonperishable food supply on hand. LPA observed sharps/ knives to be locked away and inaccessible to residents in care. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents in care.

LPA observed the perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards. The care home has smoke detectors and carbon monoxide detectors that are operable. Licensing complaint poster are posted as required. Fire extinguishers was last serviced on 5/31/2023. First aid kit are maintained and ready for emergency use.

Component III presentation conducted with administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit Interview conducted and copy of report provided.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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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