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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 11/08/2024
Date Signed: 11/08/2024 01:55:22 PM

Document Has Been Signed on 11/08/2024 01:55 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:
11/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Keith Payne, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 11/8/24 and met with the Executive Director, Keith Payne, to continue the Required-1 Year Inspection.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed three (3) bedrooms in assisted living, two (2) bedrooms in memory care, and five (5) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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