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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005454
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:06:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:A-1 ELDERLY CAREFACILITY NUMBER:
317005454
ADMINISTRATOR:EMIL TIFFACILITY TYPE:
740
ADDRESS:103 MCLAREN COURTTELEPHONE:
(916) 472-6432
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 0DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Iona Tif- Facility Staff TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10/19/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with facility staff, Iona Tif, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms.. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA requested for facility staff to call and notify Administrator, Silmona Tif, that LPA is present at the facility to conduct an annual inspection. Facility staff called Administrator via telephone. Administrator stated there are no residents at the facility. The facility had relocated residents last year and will remain closed until further notice.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, three (3) bathrooms, kitchen, and backyard. LPA observed no residents at the facility. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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