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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002975
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:58:57 PM

Document Has Been Signed on 06/27/2024 04:58 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:RNCARE HOUSEFACILITY NUMBER:
315002975
ADMINISTRATOR/
DIRECTOR:
ESTANTE, EDWARDFACILITY TYPE:
740
ADDRESS:157 VALLEYWOOD WAYTELEPHONE:
(916) 200-8067
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 0DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:55 PM
MET WITH:Hazel Estante, Co-Administrator TIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility announced to conduct a Required-1 Year Inspection. The annual was scheduled since there are currently no residents. LPA met with Hazel Estante, Co-Administrator. Also present was a family member of the Administrators who is temporarily visiting.

LPA and Co-Administrator toured the interior and exterior of the facility. LPA observed all rooms to be fully furnished and to have sufficient lighting also. All areas of the home were clean, in good repair and did not appear to post a health and safety risk. There is sufficient 7+day non-perishable food on hand and dishes and flatware in the kitchen. There are linens, blankets and towels in a hallway cabinet, and the medications will be stored in a locked file cabinet in the common area. There are PPE and paper supplies on hand as well as a complete First Aid kit. The smoke/monoxide alarms are in working order, and the fire extinguisher was last serviced in February 2024. Outside, there is a pool gated with a lock requiring a key.

LPA observed (3) binders to file staff and facility paperwork, including the Infection Control Plan and the Emergency Disaster Plan. The Administrator submitted paperwork to renew his RCFE Administrator Certificate in December 2023; the Co-Administrator is finishing completing the required educational units and will be submitting her paperwork soon.

LPA advised that the Department be notified as soon as the first resident is admitted.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided to the Co-Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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