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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920164
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:16:43 AM


Document Has Been Signed on 06/20/2024 11:16 AM - 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:ROCKLIN MODERN CAREFACILITY NUMBER:
315920164
ADMINISTRATOR:CHU, CHRISTPHERFACILITY TYPE:
740
ADDRESS:5720 MORNING SIDE CT.TELEPHONE:
(916) 202-5008
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Christopher and Patricia ChuTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday June 20, 2024 to conduct an announced prelicensing visit.

The Compliance and Regulatory Enforcement Tool was used during today's inspection. This facility has a fire clearance for 6 nonambulatory residents, with a total capacity of 6. Facility has all required postings in the entry way.

LPA toured the facility with Administrator Christopher and Patricia. The following areas were inspected for compliance: kitchen, backyard, resident rooms, bathrooms, staff rooms and common areas. Facility has a current fire extinguisher and a full first aid kit. Medications are kept locked in the dining room. Cleaning chemicals and knives/sharps are kept locked and inaccessible to residents.

Component III has been completed at this time.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted with Administrator and a copy of this report will be left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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