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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:48:06 PM


Document Has Been Signed on 04/03/2024 02:48 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ROSELEAF SENIOR CAREFACILITY NUMBER:
045002778
ADMINISTRATOR:BINGHAM, DIANIAFACILITY TYPE:
740
ADDRESS:2180 HUMBOLDT ROADTELEPHONE:
(530) 924-4804
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:16CENSUS: 0DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Stacy Baxter TIME COMPLETED:
03:00 PM
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LPA arrived at the facility for an scheduled inspection. This facility has not been in operation and does not have an active administrator or any residents in care.

LPA toured the facility to ensure that it is not in operation and that there are no residents in care.
LPA confirmed that there are no residents in care. There are no medications being stored, no medications and no indication that anyone resides in the facility.


Several topics discussed.
No Deficiencies being cited as a result of todays visit.
Exit interview conducted and a copy of this report is left at the facility.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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