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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920180
Report Date: 12/10/2024
Date Signed: 12/10/2024 11:29:26 AM

Document Has Been Signed on 12/10/2024 11:29 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:LONG CREEK HAVEN CARE HOMEFACILITY NUMBER:
315920180
ADMINISTRATOR/
DIRECTOR:		SALVA, LITAFACILITY TYPE:
740
ADDRESS:1415 LONG CREEK WAYTELEPHONE:
(916) 804-2255
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 3DATE:
12/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Lita SalvaTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensed Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived at the facility to follow up regarding concerns during last pre-licensing visit on 10/16/2024.

Facility was inspected both indoors and outdoors. LPAs inspected 5 resident bedrooms, 2 bathrooms, 1 staff room, common living areas, kitchen, and outdoor areas. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. Fire clearance was granted on 07/30/24 for 5 non-ambulatory residents and 1 bedridden resident in room near exit 3. Kitchen is clean, sanitary, and in good repair. LPAs reviewed one (1) resident record. Licensee will change admission agreement once License has been approved.

Comp III was reviewed on 10/16/2024 with licensee.

Licensee has fixed the window screens and the hole in the wall in the staff room. In addition, licensee has updated facility sketch to reflect current resident rooms.

Application is pending and LPAs will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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