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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700445
Report Date: 05/01/2023
Date Signed: 05/01/2023 02:59:07 PM


Document Has Been Signed on 05/01/2023 02:59 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:PAVILION AT EL DORADO HILLS, THEFACILITY NUMBER:
092700445
ADMINISTRATOR:MELISA TIBURCIOFACILITY TYPE:
740
ADDRESS:2288 FRANCISCO DRTELEPHONE:
(916) 542-3452
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:64CENSUS: 40DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Health Service Director Alexis PrioloTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on Monday May 1, 2023 to conduct the annual inspection. LPA wore a surgical mask during todays visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (6) and staff (4) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPAs and Health Service Director Alexis Priolo toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. LPAs observed the facility's emergency food and water storage and PPE storage. In the areas toured, there were no health or safety violations observed.

LPAs reviewed fire drills. All required postings were observed in the lobby area.

LPAs requested the facility to send updated LIC500 via email to CCLD.

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
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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