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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003908
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:34:36 AM


Document Has Been Signed on 12/14/2023 11:34 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: 1DATE:
12/14/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Zelka Tomasic, AdministratorTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Administrator, Zelka Tomasic, to conduct a case management health and safety check. LPA was joined by Long-Term Care Ombudsman (LTCO) during visit.

During visit, LPA conducted interviews with Administrator and resident (R1) and observed resident in care.

No deficiencies are being cited as a result of today's inspection.

An exit interview was conducted with the Administrator. A copy of this report was provided to the facility. Signature acknowledges receipt of this report.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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