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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700167
Report Date: 04/09/2024
Date Signed: 04/10/2024 08:59:45 AM


Document Has Been Signed on 04/10/2024 08:59 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:ALDER GROVE SENIOR LIVING IIFACILITY NUMBER:
342700167
ADMINISTRATOR:TAN, CLIFFORDFACILITY TYPE:
740
ADDRESS:637 SHOCKLEY ROADTELEPHONE:
(650) 281-6612
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 5DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Clifford Tan, LIcenseeTIME COMPLETED:
01:30 PM
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On 4/9/2024 LPA Tryon visited the facility to do an annual visit using the CARE Tool. LPA met with Licensee/Administrator Clifford Tan.

LPA toured the facility including common areas, kitchen, food storage, laundry room, bedrooms, bathrooms, hallways, outside areas. The home is nicely decorated and furnished, is clean and in good repair.
Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable. Medications are centrally stored and locked. Cleaners and chemicals are locked. Smoke detectors/carbon monoxide detectors installed and functional. Fire extinguishers present and charged. No hazards noted.

LPA Reviewed 2 resident files and 2 staff files; Interviewed one staff and 2 residents

LPA reviewed the CARE Tool with licensee. The home appears to be in substantial compliance with the regulations at this time. No deficiencies noted.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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