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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920200
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:02:28 AM

Document Has Been Signed on 12/03/2024 11:02 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:ROSEVILLE SENIOR CAREFACILITY NUMBER:
315920200
ADMINISTRATOR/
DIRECTOR:		HEGSETH, NICOLETAFACILITY TYPE:
735
ADDRESS:1740 CHELSEA WAYTELEPHONE:
(916) 542-5306
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 0DATE:
12/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Nicoleta Hegseth, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson met with Administrator, Nicoleta Hegseth, to conduct a Pre- Licensing visit. The facility has a fire clearance for one (1) ambulatory resident and five (5) non-ambulatory residents. Administrator Nicoleta Hegseth has an active certificate (#6058750740 with expiration date 2/15/2025).

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and three (3) bathrooms for resident use. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 110.1 degrees F. LPAs observed facility has the ability to prepare and store food, to lock away cleaning products and other toxins, and lock medications to make inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detectors at the care home to be operational.

Component III was waived. 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: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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