<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004677
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:41:36 AM


Document Has Been Signed on 06/02/2022 10:41 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CALVINE ELDERLY CARE HOMEFACILITY NUMBER:
347004677
ADMINISTRATOR:NITA, ELENAFACILITY TYPE:
740
ADDRESS:10547 CALVINE RD.TELEPHONE:
(916) 688-9132
CITY:SACRAMENTOSTATE: CAZIP CODE:
95830
CAPACITY:6CENSUS: 0DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elena NitaTIME COMPLETED:
10:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On June 2, 2022 at 10:30 AM, Licensing Program Analyst (LPA) Chris Hopkins arrived at facility announced to conduct an inspection proceeding the closure of the facility. LPA met with Administrator Elena Nita and explained the purpose of the visit. LPA received a copy of the 60day notice given to residents on 5/4/22. All residents moved out before 60 days.

LPA toured the facility with the administrator. LPA observed that there were no residents at the facility. Administrator has surrendered the original license to LPA.

A copy of this report was left Administrator Elena Nita.

Link to survey for Facility Closure provided to Administrator.

www.surveymonkey.com/r/facilityclosure
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1