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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000989
Report Date: 10/09/2024
Date Signed: 10/09/2024 10:43:59 AM

Document Has Been Signed on 10/09/2024 10:43 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:ROSEVILLE ADULT CENTERFACILITY NUMBER:
317000989
ADMINISTRATOR/
DIRECTOR:		DEVON MARTINEZFACILITY TYPE:
775
ADDRESS:531 VERNON STREETTELEPHONE:
(916) 783-5700
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 75CENSUS: 39DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Devon MartinezTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 10/9/24 to conduct a Required-1 Year Inspection LPA met with the Program Director(PDP, and explained the purpose of the visit.

LPA inspected the facility interior. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and PD discussed postings for Ombudsman and CCLD complaints poster.

LPA reviewed 4 staff files and 4 client files. Files were found to be complete for required information.
LPA and director discussed that new staff have client safety topics prioritized at on-boarding.

LPA provided a copy of a current LIC 500- Personnel Report.

The program is clean, safe and well staffed for the current clients in care.

No deficiencies are being cited as a result of todays inspection.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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