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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005554
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:24:50 PM


Document Has Been Signed on 09/05/2023 03:24 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:EL DORADO HILLS SENIOR CAREFACILITY NUMBER:
097005554
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2904 TAM O'SHANTER DRIVETELEPHONE:
(916) 933-0107
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 4DATE:
09/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Administrator Jennifer HinchTIME COMPLETED:
03:25 PM
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Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 9/5/2023 and met with Licensee, Ben Foulk and Administrator Jennifer Hinch and explained the purpose of the visit.

The Department conducted a joint visit today with El Dorado Hills Fire District. On 02/21/2023, the fire district issued the facility a correction notice with items that needed to be corrected for the facility to meet fire code requirements. As of this date, the noted deficiencies have not been corrected. The fire district will be issuing a second correction notice today with a due date of 7 calendar days from today’s date. A follow up visit will be conducted to ensure that corrections have been made.

Exit interview conducted and report left with Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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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