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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003908
Report Date: 01/30/2024
Date Signed: 01/30/2024 11:09:44 AM


Document Has Been Signed on 01/30/2024 11:09 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:FAIR OAKS CARE HOME AT MONTE PARKFACILITY NUMBER:
347003908
ADMINISTRATOR:TOMASIC, ZELKAFACILITY TYPE:
740
ADDRESS:8156 MONTE PARK AVENUETELEPHONE:
(916) 267-3867
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:5CENSUS: 0DATE:
01/30/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Zelka Tomasic, LicenseeTIME COMPLETED:
11:25 AM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with Licensee, Zelka Tomasic, to conduct an inspection for the closure of the facility.

LPAs observed interior/exterior of the facility, including the yard, common areas, dining room, kitchen, and bedrooms. LPAs observed that there were no residents at the facility.

LPAs obtained a Notice of Facility Closure from Licensee. LPAs received the original License and the facility will be closed in the system as of 1/30/2024.

Exit interview conducted. Copy of the report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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