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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005454
Report Date: 10/16/2024
Date Signed: 10/16/2024 03:10:50 PM


Document Has Been Signed on 10/16/2024 03:10 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: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: 2DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Simona TifTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/16/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with acting Administrator, Simona Tif who assisted with the visit. LPA to update facility records to change the Administrator designation.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents care needs appear to be met.

LPA reviewed 2 resident files. Files are complete and well organized.

LPA confirmed that Administrator, who is the acting caregiver, has current certification.

LPA advised Administrator of the CARE inspection tool being available online. LPA provided a copy of PIN 22-24-ASC regarding collaborating with Home Health and Hospice.


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


Exit interview conducted with licensee and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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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