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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005452
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:29:03 PM


Document Has Been Signed on 10/02/2024 12:29 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: 3DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Emil TifTIME COMPLETED:
12:40 PM
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Licensing Program Analysts (LPA) Graham Gunby and Cheyenne Ratajczak arrived on Wednesday October 2, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed client (3) and staff (1) files. All client files contained the required paperwork. All staff files contained the required paperwork and training.

LPAs and Administrator Emil toured the facility together to ensure the health and safety of clients in care. The areas toured included bedrooms, office, kitchen, bathrooms, back yard and common areas. All chemicals, toxins and knives were kept locked and inaccessible to clients. Facility has one (1) fire extinguishers, in the entry. In the areas toured, there were no health or safety violations observed.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Graham GunbyTELEPHONE: (916) 827-6870
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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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