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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002973
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:42:27 PM

Document Has Been Signed on 09/11/2024 03:42 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MORGAN CREEK VILLAFACILITY NUMBER:
315002973
ADMINISTRATOR/
DIRECTOR:		KING, ROBERTFACILITY TYPE:
740
ADDRESS:9565 PINEHURST DRIVETELEPHONE:
(916) 846-3169
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
09/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Mari King, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi and Graham Gunby arrived unannounced to conduct a case management visit. During today's inspection LPA met with Administrator Mari King for a case management visit.

LPA was following up on a potential eviction notice being provided to resident. Administrator stated eviction notice was not issued to resident. Administrator stated resident is in the hospital and family stated resident will not return to facility.

No deficiencies cited during today's inspection.

Exit interview conducted and copy of report given.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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