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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920123
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:23:38 PM


Document Has Been Signed on 06/18/2024 01:23 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:MORGAN CREEK COMFORT CARE HOMEFACILITY NUMBER:
315920123
ADMINISTRATOR:RAZA, SARDAR ALIFACILITY TYPE:
740
ADDRESS:9660 PINEHURST DRIVETELEPHONE:
(414) 243-1004
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 0DATE:
06/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sardar Ali Raza, Administrator TIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived announced to conduct a pre-licensing inspection. LPA met with Sardar Ali Raza during today's visit.

LPA arrived to verify grab bars were installed in bathrooms. LPA observed Administrator has placed grab bars in the bathrooms.

Licensee is required to contact Community Care Licensing upon the admittance of their first consumer, after licensure. This report will be forwarded to the centralized application unit for continued processing.

Exit interview and copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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