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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:08:34 PM

Document Has Been Signed on 11/07/2024 03:08 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:ANSEL PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR/
DIRECTOR:		PAYNE, KEITHFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 100CENSUS: 77DATE:
11/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Keith Payne, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 11/7/24, and met with the Executive Director, Keith Payne, to follow-up on a plan of correction (POC).

During today's visit, LPA checked the water temperature in three (3) apartments in Assisted Living and one (1) in Pathways Memory Care. Apartment #100 had a water temperature of 105.2 degrees F in the bathroom sink. Apartment #168 had a water temperature of 112.5 degrees F in the kitchen sink. Apartment #169 had a water temperature of 112.3 degrees F in the bathroom sink. Apartment #179 had a water temperature of 111.4 degrees F in the bathroom sink. All apartments had water temperatures within regulatory range. Facility provided the most recent invoice for the repairs made to resolve the water temperature issue, as well as the facility's most current water temperature log. The POC was cleared during today's visit.

Exit interview conducted. A copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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