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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
345002839
Report Date:
01/11/2023
Date Signed:
01/11/2023 12:47:03 PM
Document Has Been Signed on
01/11/2023 12:47 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
CCLD Regional Office
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
EMERALD ESTATE SENIOR LIVING
FACILITY NUMBER:
345002839
ADMINISTRATOR:
COSTAR, KIMI
FACILITY TYPE:
740
ADDRESS:
7100 KENNETH AVE
TELEPHONE:
(916) 947-6155
CITY:
ORANGEVALE
STATE:
CA
ZIP CODE:
95662
CAPACITY:
6
CENSUS:
5
DATE:
01/11/2023
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
12:05 PM
MET WITH:
Staff- Garrison Costar
TIME COMPLETED:
01:00 PM
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Post Licensing visit is conducted in today's inspection.
No deficiencies are cited.
See 809 for Annual visit for details.
Exit interview done and copy of the report left at facility.
SUPERVISOR'S NAME:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Talwinder Bains
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
01/11/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/11/2023
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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