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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700326
Report Date: 09/27/2023
Date Signed: 09/27/2023 10:54:12 AM


Document Has Been Signed on 09/27/2023 10:54 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:ROSEBERRY CAREFACILITY NUMBER:
342700326
ADMINISTRATOR:QUISTGUARD, JESSICAFACILITY TYPE:
740
ADDRESS:128 BERRY STREETTELEPHONE:
(916) 780-3369
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:15CENSUS: 13DATE:
09/27/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica QuistgardTIME COMPLETED:
11:00 AM
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On 9/27/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a collateral visit. LPAs met with caregiver, who contacted Administrator who arrived to the facility shortly afterwards.

During today's visit, LPAs spoke with Administrator and R1 on an issue that was not related to this facility.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

Exit Interview conducted and a copy of the report was provided to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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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