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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005915
Report Date: 09/14/2023
Date Signed: 09/14/2023 11:03:11 AM

Document Has Been Signed on 09/14/2023 11:03 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:DAYCATION FOR SENIORSFACILITY NUMBER:
317005915
ADMINISTRATOR:KELLY, PAULFACILITY TYPE:
775
ADDRESS:6011 STANFORD RANCH DR #104TELEPHONE:
(916) 698-7555
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 60CENSUS: 28DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Helene Share, ReceptionistTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Helene Share during today's inspection. LPA called Administrator Paul Kelly to inform them of inspection.

LPA toured facility with receptionist to ensure health and safety of clients in care. LPA toured common areas, kitchen area, and bathrooms. Facility provides lunch and snacks throughout the day. Kitchen was clean and in good repair. In the areas toured no immediate health, safety, or personal rights violations were observed. There is a locked storage for medications and toxins.

LPA reviewed 2 client files and 2 staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed.

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

Exit interview conducted and copy of report given.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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