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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005554
Report Date: 12/10/2024
Date Signed: 12/10/2024 09:50:42 AM

Document Has Been Signed on 12/10/2024 09:50 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:EL DORADO HILLS SENIOR CAREFACILITY NUMBER:
097005554
ADMINISTRATOR/
DIRECTOR:		SERGEI ENTONAFACILITY TYPE:
740
ADDRESS:2904 TAM O'SHANTER DRIVETELEPHONE:
(916) 933-0107
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 0DATE:
12/10/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:RCC Serge EntonaTIME VISIT/
INSPECTION COMPLETED:
09:51 AM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 12/10/24 to conduct a health and safety check. LPA met with RCC Serge Entona and explained the purpose of the visit.

During today's visit, the Department checked the food supply and did a brief walk through the facility with staff. No concerns noted. The facility has not had any residents since February/March 2024.

No citations were issued per Title 22 Regulations.

Exit interview conducted and copy of the report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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