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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 11:07:53 AM


Document Has Been Signed on 01/30/2024 11:07 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:POCUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Zelka Tomasic, LicenseeTIME COMPLETED:
11:05 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 follow-up on a plan of correction made to the facility on 11/21/2023 to be completed on 1/22/2024.

Facility is closed as of 1/30/2024. LPAs cleared all deficiencies during visit.

Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
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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