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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005915
Report Date: 08/07/2024
Date Signed: 08/07/2024 10:44:07 AM

Document Has Been Signed on 08/07/2024 10:44 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:DAYCATION FOR SENIORSFACILITY NUMBER:
317005915
ADMINISTRATOR/
DIRECTOR:		KELLY, PAULFACILITY TYPE:
775
ADDRESS:6011 STANFORD RANCH DR #104TELEPHONE:
(916) 698-7555
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 60CENSUS: 35DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Helene Share - ReceptionistTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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On 08/07/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced to conduct an annual inspection. LPA met with Receptionist, Helene Share and explained the purpose of the visit. Receptionist 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. In the areas toured no immediate health, safety, or personal rights violations were observed. There is a locked storage for medications and toxins. Fire extinguisher was last inspected on 05/13/24.

LPA reviewed five (5) client files and two (2) staff files. Staff records reviewed indicated current first aid/ CPR certificates.

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

Exit interview conducted and copy of report given.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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