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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002837
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:57:13 PM

Document Has Been Signed on 01/24/2025 03:57 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:CROWN POINT VILLAFACILITY NUMBER:
315002837
ADMINISTRATOR/
DIRECTOR:		NABUGO, EDITHFACILITY TYPE:
740
ADDRESS:1001 TAMARACK COURTTELEPHONE:
(301) 541-4028
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:38 PM
MET WITH:Violet MubeeziTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Licensee and explained the purpose of the visit.

Today's census is five residents in care, with two residents on hospice. LPA was informed at once point there was four residents on hospice services. Facility is licensed for hospice waiver of two, but upon file review, it revealed hospice waiver increase was approved in 2022 but license was never updated. LPA informed facility it will be updated and new license will be mailed.

LPA and Licensee conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: residents bedroom, bathrooms, laundry, kitchen, backyard, garage and common areas.

During today's visit, LPA was unable to complete visit. Visit will be continued at a later date.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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