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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700098
Report Date: 12/20/2023
Date Signed: 12/20/2023 11:09:15 AM


Document Has Been Signed on 12/20/2023 11:09 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:CARMICHAEL SENIOR CAREFACILITY NUMBER:
342700098
ADMINISTRATOR:DIZON, MARIA SUSIE VFACILITY TYPE:
740
ADDRESS:5208 FAIR OAKS BLVDTELEPHONE:
(916) 973-9533
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 0DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Maria Susie DizonTIME COMPLETED:
11:30 AM
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On 12/20/2023, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced to conduct a required annual inspection. LPA observed facility to be vacant. LPA contacted caregiver who contact Administrator who arrived to the facility at approximately 10:55AM.

LPA was informed all residents relocated to a sister facility to be closer to family members recently. LPA and Administrator conducted a tour of the interior of the facility and noticed a broken window in a bedroom. LPA informed Administrator to repair the window prior to new resident admission.

During today's visit, LPA and Administrator discussed informing Licensing if facility wants to close or if facility would like to remain census of zero (0) but with active license.

Exit interview and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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