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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002994
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:19:31 PM

Document Has Been Signed on 03/09/2023 04:19 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:BLUE OAKS SENIOR CAREFACILITY NUMBER:
315002994
ADMINISTRATOR:ALDEA, SABRINAFACILITY TYPE:
740
ADDRESS:4065 PEABODY WAYTELEPHONE:
(916) 617-8834
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 0DATE:
03/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sabrina Aldea, Administrator TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived announced to conduct a pre-licensing inspection. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.

Facility was inspected both indoors and outdoors. LPA inspected 5 resident bedrooms, 3 bathrooms, common living areas, garage and kitchen. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. First aid kit was present in the facility. Centrally stored medications will be locked in the kitchen area cabinet. The facility has adequate lighting throughout and night lights in the hallways. LPA inspected resident bedroom and the bedroom had appropriate furnishings, chair, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. LPA observed grab bars and non-skid mats present in the bathrooms. Smoke detectors and carbon monoxide detectors were checked and operational. Fire clearance was granted on 01/27/23 for 5 non-ambulatory and 1 bedridden resident. Kitchen is clean, sanitary, and in good repair. A working telephone has been set up for resident use.

Competent III was completed during today's inspection with licensee. Licensee is required to contact Community Care Licensing upon the admittance of their first consumer, after licensure. This report will be forwarded to the centralized application unit for continued processing.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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