<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005454
Report Date: 09/20/2023
Date Signed: 09/20/2023 09:07:45 AM


Document Has Been Signed on 09/20/2023 09:07 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: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:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator: Simona TifTIME COMPLETED:
09:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 09/20/2023 to conduct a Required-1 Year Inspection. LPA met with facility staff, Simona Tif, and explained the purpose of the visit.

LPA and administrator toured the interior and exterior of the facility. There are no residents at the facility. Facility is current and active. Facility is temporarily not operating at this time. LPA notes that Licensee will maintain licensure and will update Community Care Licensing (CCL) with any changes.

No deficiencies cited.

Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1