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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002837
Report Date: 01/31/2025
Date Signed: 01/31/2025 11:16:19 AM

Document Has Been Signed on 01/31/2025 11:16 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: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:
01/31/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Violet MubeeziTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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On January 31, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual continuation case management visit. LPA met with Licensee and explained the purpose of the visit.

During today's inspection, LPA conducted a file review for five residents and four personnel records. LPA observed required documents present. LPA and Licensee discussed that all resident medical assessment should be completely annually and/or with change of condition.

LPA was informed Licensee has an appointment for the following Monday for fire extinguisher inspection. Licensee is to submit a photo of inspection tag once completed. Pool gate observed to be locked and inaccessible to residents in care.

LPA observed a copy of active Administrator Certificate present. LPA observed facility liability insurance to be active.

At this time, LPA is requesting a copy of LIC 500 and LIC 308 to be emailed to LPA by Friday February 7, 2025.

No deficiencies cited.

Exit interview conducted and a copy of report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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