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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700763
Report Date: 04/05/2023
Date Signed: 04/05/2023 03:44:18 PM


Document Has Been Signed on 04/05/2023 03:44 PM - 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:A-1 ELDERLY CAREFACILITY NUMBER:
342700763
ADMINISTRATOR:TIF, ROBERTFACILITY TYPE:
740
ADDRESS:5210 ROBERTSON AVETELEPHONE:
(916) 996-4763
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
04/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Robert TifTIME COMPLETED:
03:45 PM
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On 4/5/23, LPA Mknelly came to the home and met with the licensee.
LPA mistakenly came to the wrong facility.

LPA and licensee discussed clearance and association issues.
Licensee stated understanding of the requirements.

No deficiencies are cited as a result of this visit.

Report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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