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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005452
Report Date: 11/14/2023
Date Signed: 11/14/2023 01:30:20 PM


Document Has Been Signed on 11/14/2023 01:30 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:FLORADALE VILLAFACILITY NUMBER:
317005452
ADMINISTRATOR:TIF, EMILFACILITY TYPE:
740
ADDRESS:2688 FLORADALE WAYTELEPHONE:
(916) 543-9029
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 1DATE:
11/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Emil TifTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday November 14, 2023 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (1) and staff files (2). Resident file contained the required paperwork. All staff files contained the required paperwork. First aid kit was fully stocked. Facility had a full supply of PPE including face shields, surgical masks, N95s, and gowns. Facility was clean and well organized. All required posting were observed.

LPA Parks and Emil toured the facility together to ensure the health and safety of resident in care. The areas toured included resident rooms (occupied and unoccupied), bathrooms, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed.

Administrator will email LPA a copy of the current liability insurance.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2023
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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