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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002577
Report Date: 10/29/2019
Date Signed: 12/08/2020 08:33:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ELDERLY INN IIFACILITY NUMBER:
347002577
ADMINISTRATOR:LEAL, RUBENFACILITY TYPE:
740
ADDRESS:5210 ROBERTSON AVENUETELEPHONE:
(916) 972-7003
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 0DATE:
10/29/2019
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:spouse of respondentTIME COMPLETED:
11:50 AM
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**This report is being amended from the original dated 10/29/2019 to remove confidential information that was inadvertently contained in the original report. **

Licensing Program Analyst (LPA's) Calzada and Mknelly arrived at place of residence for respondent, Ruben Leal.

NOTE: LPA's noted that there is not an existing address, as listed on the exclusion notice, but respondent lives at a nearby location on the same street. LPA's contacted regional office to advise of address error on exclusion notice. LPA's also noted that date of letter is shown as 10/30/19 instead of 10/29/19. LPM advised that exclusion letter will need to be modified with a new signature and that an updated version would be e-mailed as soon as a signature is obtained.

LPA's received updated signed letter while in the field and printed a copy to serve respondent. LPA's approached respondent's address and knocked on the door. Female who answered confirmed she is respondent's wife and respondent is at work and would arrive at home around 5 pm. LPA Mknelly stated that he had a letter to give to respondent which pertains to an exclusion order. LPA's left location and stated they would return later.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2019
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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