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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003908
Report Date: 05/09/2022
Date Signed: 05/09/2022 05:15:22 PM


Document Has Been Signed on 05/09/2022 05:15 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,
, CA



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: DATE:
05/09/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Zelka TomasicTIME COMPLETED:
05:00 PM
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On 5/9/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a collateral visit. LPA Jensen met with Licensee Zelka Tomasic and explained the purpose of today's visit.

LPA Jensen conducted an interview with the Licensee regarding a prior resident (R1). LPA Jensen also reviewed the resident file for R1. LPA Jensen requested the Licensee follow up with LPA Jensen to provide a letter from a placement agency with a new contract they were proposing. LPA Jensen requested the document be emailed to maja.jensen@dss.ca.gov.

An exit interview was conducted and a copy of this report was emailed to the licensee.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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